Legislature(2019 - 2020)CAPITOL 106

03/07/2019 03:00 PM House HEALTH & SOCIAL SERVICES

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Audio Topic
03:02:37 PM Start
03:03:20 PM Presentation: Alaska Psychiatric Institute
05:05:47 PM Presentation: Wellpath Recovery Solutions
06:23:33 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: AK Psychiatric Institute with TELECONFERENCED
Dept. of Health & Social Services Administration
& Stakeholders
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         March 7, 2019                                                                                          
                           3:02 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Ivy Spohnholz, Co-Chair                                                                                          
Representative Tiffany Zulkosky, Co-Chair                                                                                       
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Geran Tarr                                                                                                       
Representative Sharon Jackson                                                                                                   
Representative Lance Pruitt                                                                                                     
MEMBERS ABSENT                                                                                                                
All members present                                                                                                             
OTHER LEGISLATORS PRESENT                                                                                                     
Representative Andy Josephson                                                                                                   
Representative Dan Ortiz                                                                                                        
COMMITTEE CALENDAR                                                                                                            
PRESENTATION: ALASKA PSYCHIATRIC INSTITUTE                                                                                      
     - HEARD                                                                                                                    
PRESENTATION: WELLPATH RECOVERY SOLUTIONS                                                                                       
     - HEARD                                                                                                                    
PREVIOUS COMMITTEE ACTION                                                                                                     
No previous action to record                                                                                                    
WITNESS REGISTER                                                                                                              
ALBERT WALL, Deputy Commissioner                                                                                                
Office of the Commissioner                                                                                                      
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented a PowerPoint titled "Alaska                                                                    
Psychiatric Institute."                                                                                                         
JEREMY BARR, President                                                                                                          
WellPath Recovery Solutions                                                                                                     
Nashville, Tennessee                                                                                                            
POSITION  STATEMENT:   Presented  a  PowerPoint titled  "Wellpath                                                             
Recovery Solutions."                                                                                                            
DR. KEVIN ANN HUCKSHORN, Senior Consultant                                                                                      
Wellpath Recovery Solutions                                                                                                     
Nashville, Tennessee                                                                                                            
POSITION  STATEMENT:   Presented  a  PowerPoint titled  "Wellpath                                                             
Recovery Solutions."                                                                                                            
ACTION NARRATIVE                                                                                                              
3:02:37 PM                                                                                                                    
CO-CHAIR  TIFFANY ZULKOSKY  called  the House  Health and  Social                                                             
Services  Standing  Committee  meeting  to  order  at  3:02  p.m.                                                               
Representatives  Zulkosky,   Spohnholz,  Pruitt,   Tarr,  Claman,                                                               
Drummond, and Jackson  were present at the call to  order.  Also,                                                               
in attendance were Representatives Josephson and Ortiz.                                                                         
^PRESENTATION:  ALASKA PSYCHIATRIC INSTITUTE                                                                                  
          PRESENTATION:  ALASKA PSYCHIATRIC INSTITUTE                                                                       
3:03:20 PM                                                                                                                    
CO-CHAIR  ZULKOSKY announced  that  the first  order of  business                                                               
would be a presentation on the Alaska Psychiatric Institute.                                                                    
3:04:43 PM                                                                                                                    
The committee took a brief at-ease.                                                                                             
3:05:38 PM                                                                                                                    
ALBERT  WALL, Deputy  Commissioner, Office  of the  Commissioner,                                                               
Department  of  Health and  Social  Services,  presented a  Power                                                               
Point titled  "Alaska Psychiatric  Institute."  He  reported that                                                               
upon  appointment to  Department  of Health  and Social  Services                                                               
both  he  and  Commissioner  Crum  were  aware  that  there  were                                                               
extenuating  circumstances at  the  Alaska Psychiatric  Institute                                                               
(API), which he  described as "difficult."  He  added that "there                                                               
was a lack of open beds,  lack of staffing, and there were safety                                                               
and  security  issues  including   the  issue  of  restraint  and                                                               
seclusion."   He  opined  that,  at the  outset,  neither he  nor                                                               
Commissioner Crum  were aware for  the severity of  the problems.                                                               
He  pointed specifically  to the  "timeline of  certification and                                                               
survey process  for plans  of correction."   He  reported finding                                                               
several critical  issues at  API, and he  shared slide  2, titled                                                               
"Critical  Issues at  the Alaska  Psychiatric Institute."   These                                                               
issues included  staff and patient  safety, inability  to fulfill                                                               
its mission, pending legal issues  with extreme risk of high cost                                                               
to the state, and the ethical treatment of Alaskans.                                                                            
3:07:28 PM                                                                                                                    
MR. WALL  introduced slide 3, titled  "Regulatory Relationships,"                                                               
which depicted an overview of  the regulatory authorities at API.                                                               
He   pointed  to   Professional   Licensing,   noting  that   the                                                               
requirements changed  for each  type of  profession and  each had                                                               
its own  licensing requirements which  delineated what  could and                                                               
could not  be done for  health care.  He  noted that each  of the                                                               
remaining  regulatory  bodies   were  outside  the  organization,                                                               
looking in at conditions in the hospital.                                                                                       
3:08:17 PM                                                                                                                    
MR.  WALL introduced  slide 4,  "Occupational  Safety and  Health                                                               
Administration," reporting  that this was  a Federal  agency that                                                               
sets  and   enforces  protective  workplace  safety   and  health                                                               
standards,  and  that  it  may  levy fines  on  agencies  not  in                                                               
compliance.  He  referenced  a report  that  the  department  had                                                               
received    from   OSHA    (Occupational   Safety    and   Health                                                               
Administration) which declared that API was an unsafe workplace.                                                                
3:08:49 PM                                                                                                                    
MR. WALL moved  on to slide 5, "Alaska  Ombudsman," and explained                                                               
that among  the many services provided,  this agency investigates                                                               
complaints   that   involve   state   agencies   and   determines                                                               
appropriate  remedies.   The Alaska  Ombudsman  had initiated  an                                                               
investigation in  July of 2018  and the final report  of findings                                                               
was  given  to  the  Department of  Health  and  Social  Services                                                               
yesterday [March 6, 2019] evening.                                                                                              
3:09:33 PM                                                                                                                    
MR.  WALL   addressed  slide  6,  "The   Joint  Commission,"  and                                                               
explained that  this was  a national,  not-for-profit accrediting                                                               
organization  for nearly  21,000 health  care organizations.   It                                                               
provides  peer-to-peer   standards  for  members,   offers  joint                                                               
evaluations, and holds and certifies  each member to professional                                                               
standards.  He  added that the commission could also  be an agent                                                               
for the  Centers for Medicaid  and Medicare Services and  may act                                                               
in their  stead to inform  on deficiencies in organizations.   He                                                               
added that API was currently under  a plan of correction with the                                                               
Centers for Medicaid and Medicare Services.                                                                                     
3:10:30 PM                                                                                                                    
MR.  WALL presented  slide 7,  "Health  Facilities Licensing  and                                                               
Certification," which  read:  "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."                                                                                                                
CO-CHAIR SPOHNHOLZ asked  if any hospital in Alaska  had lost its                                                               
MR. WALL  replied that  he would find  out and "I  can get  it to                                                               
3:11:23 PM                                                                                                                    
MR. WALL  directed attention  to slide  8, "Centers  for Medicare                                                               
and Medicaid Services."   He added that, as  Medicaid evolved out                                                               
of the Medicare law, Medicare itself  was the "key to all federal                                                               
funding, it's  all tied up  in the  same statute federally."   He                                                               
stated  that CMS  (Centers for  Medicare  and Medicaid  Services)                                                               
provided oversight  for health care  services and  controlled all                                                               
federal funding  to all facilities  and providers  throughout the                                                               
nation.  He reported that  API received approximately $23 million                                                               
annually in federal  funding, dependent on how  much Medicaid was                                                               
billed each year.  API  must meet federal requirements to receive                                                               
funding   and    meet   Conditions   of    Participation   (CoPs)                                                               
(certification  of   compliance  with   the  health   and  safety                                                               
requirements).     If   these  conditions   are   not  met,   the                                                               
certification would be  withdrawn and there would not  be the use                                                               
of any  federal funds.   He pointed  out that there  were several                                                               
surveys at  every facility  through CMS, and  that some  of these                                                               
were triggered  by complaints filed  for issues at  the facility,                                                               
or by  a report  of harm  or a  report of  an incident  which was                                                               
required to be  reported to a CMS authority.   He noted that some                                                               
of these  surveys were  on a routine  basis to  ensure compliance                                                               
with the rules and regulations.                                                                                                 
3:12:58 PM                                                                                                                    
MR. WALL  moved on to  slide 9, "Conditions of  Participation for                                                               
federal funding."   He stated  that API must be  in "substantial"                                                               
compliance  with each  Condition  of Participation,  which was  a                                                               
little bit  different for each type  of facility.  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.                                                                                         
3:13:42 PM                                                                                                                    
MR. WALL presented slide 10,  "Types of Citations," and explained                                                               
the three  types of citations that  could be issued in  a survey,                                                               
although each of these three  consisted of hundreds of individual                                                               
types of deficiencies:  standard  level deficiency, which was out                                                               
of compliance  with a specific  regulation that could  usually be                                                               
easily  fixed;   condition  level  deficiency,  which   was  very                                                               
serious, as the  facility would be found to be  not in compliance                                                               
with  its  CoP, although  this  was  fixable  through a  plan  of                                                               
correction  in   an  ongoing  fashion;  and   finally,  immediate                                                               
jeopardy, which  was deviation from regulatory  standards and was                                                               
an immediate threat to patient  health and safety, including life                                                               
or limb, or a humanitarian  issue.  He labeled immediate jeopardy                                                               
as a "showstopper"  which could lead to an  immediate shutdown of                                                               
a  facility if  it was  not immediately  dealt with  in a  manner                                                               
satisfactory to the survey team.                                                                                                
3:14:53 PM                                                                                                                    
MR. WALL  directed attention to  slide 11,  "Immediate Jeopardy,"                                                               
which  was defined  by the  CMS State  Operations Manual  as "[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."                                                                       
3:15:14 PM                                                                                                                    
MR. WALL shared slide 12,  "Plans of Correction," and stated that                                                               
these plans  start as a  negotiation with CMS after  their survey                                                               
and  findings  are  presented  to the  hospital.    Although  the                                                               
Hospital has  10 calendar days  to provide an acceptable  Plan of                                                               
Correction  for  each  cited  deficiency, the  plan  may  not  be                                                               
accepted initially  by CMS.   If the  hospital doesn't  come into                                                               
compliance   by  the   deadline,  the   state  agency   certifies                                                               
"noncompliance."  He explained that  the first plan of correction                                                               
had   90  days,   with  a   subsequent  re-survey   to  determine                                                               
substantial compliance.   If  still not  in compliance,  this was                                                               
extended an  additional 90 days.   The  hospital would be  out of                                                               
time after 180 days, and there were not any more extensions.                                                                    
CO-CHAIR  SPOHNHOLZ asked  about  the date  for  the event  which                                                               
initiated the Plan of Correction for API.                                                                                       
MR.  WALL, in  response, explained  that every  time there  was a                                                               
survey team  which found a  deficiency, a plan of  correction was                                                               
written.  He stated that, currently,  API was under many plans of                                                               
correction, with the latest being on  January 29.  He pointed out                                                               
that API was  still working on plans of  correction from previous                                                               
visits.   He added that  plans of correction could  have multiple                                                               
dates, as they were working from multiple survey dates.                                                                         
CO-CHAIR SPOHNHOLZ asked  if it was "fairly common  that there is                                                               
an  issue that's  been identified  that a  plan of  correction is                                                               
requested and  then you provide  the plan of correction  and then                                                               
there's routine follow-up just to  make sure that you're actually                                                               
MR. WALL replied that was correct.                                                                                              
CO-CHAIR SPOHNHOLZ  asked if this  was typical and  happened with                                                               
fair frequency.                                                                                                                 
MR. WALL  replied that  it depended on  the level  of deficiency.                                                               
He reported  that API had  a survey  team from a  regulatory body                                                               
engaged  in a  high  level  of scrutiny  and  involvement in  the                                                               
building almost every other week for the previous 8 - 9 months.                                                                 
MR. WALL  moved on to  slide 13, "API  Plans of Correction."   He                                                               
reported that the  180-day timeline mark for API  compliance on a                                                               
Plan of  Correction had been passed  on November 26.   He pointed                                                               
out  that there  was  not  a plan  of  correction  that had  been                                                               
accepted by  the federal government  for the July  survey, noting                                                               
that  the July  survey had  been on  the day  of the  earthquake,                                                               
resulting in  a state of  emergency.  Consequently, API  had been                                                               
granted another extension which expired on February 1.                                                                          
3:19:13 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ asked  if  Mr. Wall  was  discussing the  CMS                                                               
citations dated July  19, and the Plan of  Correction in response                                                               
to this citation.                                                                                                               
MR. WALL suggested  that this was correct.  He  added that a Plan                                                               
of  Correction  was  a  dialogue   between  the  agency  and  the                                                               
government, and  he offered  his understanding  that, as  of that                                                               
date,  there was  not a  plan  to which  both sides  agreed.   He                                                               
clarified that this did not mean  that work was not being done to                                                               
come  into  compliance  with  the   issues  or  to  mitigate  the                                                               
deficiencies.  It only meant  that the documentation had not been                                                               
CO-CHAIR SPOHNHOLZ  reported that  she had  reviewed a  series of                                                               
survey  citation  reports in  which  the  former director,  Duane                                                               
Mays, had responded  to CMS.  She noted that  these documents had                                                               
been dated and  signed on September 17, 2018, most  of which were                                                               
due  to be  completed in  November.   She asked  if Mr.  Wall was                                                               
indicating that there had not been any progress on any of these.                                                                
MR.  WALL  replied  that,  although  work  was  being  done,  the                                                               
finalized version of  the plan of correction had  not been agreed                                                               
upon by both sides.                                                                                                             
REPRESENTATIVE  SPOHNHOLZ  asked  to  ensure  that  work  was  in                                                               
progress, and  it was not  as if  the issues had  been identified                                                               
but no work had been done.                                                                                                      
MR. WALL  expressed his agreement  that work  had been done.   He                                                               
relayed  that  it was  necessary  to  have  an accepted  plan  of                                                               
correction and  then show substantial  compliance with  that plan                                                               
by the  time the  survey team  returned.   He offered  an example                                                               
from the previous administration in  which the plan of correction                                                               
had  taken a  long while  to put  together and,  as the  date for                                                               
return of  the survey  team "was  looming," there  was less  of a                                                               
chance  for  showing  substantial  compliance.    He  offered  an                                                               
example  for  the difficulty  of  scheduling  new staff  training                                                               
while still maintaining full staffing during work shifts.                                                                       
3:22:01 PM                                                                                                                    
MR. WALL  moved on to  slide 14, "Seclusion &  Restraint," adding                                                               
that this was a specific  problem resulting in numerous citations                                                               
for  API and  had been  the bulk  of the  findings in  the survey                                                               
prior to January 29.  He  stated that seclusion and restraint was                                                               
a difficult and tenuous issue  in psychiatric care.  He explained                                                               
that  some patients,  admitted  civilly under  Title  47, were  a                                                               
danger to themselves  or others.  This could  result in seclusion                                                               
and restraint through a court  issuance which could only last for                                                               
a short  period of  time and  only for  emergent self-protection.                                                               
He  added that  other patients,  admitted criminally  under Title                                                               
12,  had been  evaluated  for restorative  care  for purposes  of                                                               
competency to  stand trial for the  crime to which they  had been                                                               
charged.    He noted  that  these  patients could  be  dangerous.                                                               
Seclusion   and  restraint   were   a   reality  for   in-patient                                                               
psychiatric care,  although it  was "a  difficult line  to walk."                                                               
He reported  that API  had a  much higher  rate of  seclusion and                                                               
restraint  than  was accepted  in  the  field, noting  that  many                                                               
examples had  been posted for  instances when it  possibly should                                                               
not have been occurred, especially for the length of time.                                                                      
3:23:48 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ  asked about the high  seclusion and restraint                                                               
rates and how they compared to the national standard.                                                                           
MR. WALL  replied that  these charts were  posted on  the website                                                               
with  a  monthly  standardized   report  showing  the  API  rates                                                               
compared to the national average.                                                                                               
CO-CHAIR SPOHNHOLZ mused that API  did appear "a little bit high"                                                               
and in  "other areas  we're kind  of in the  middle."   She asked                                                               
what was the concrete benchmark,  and where was API in actuality.                                                               
She pointed out  occasional spikes in the chart,  noting that one                                                               
challenging  patient could  be the  cause.   She asked  to better                                                               
understand  what the  normal standard  was  and why  it would  be                                                               
occasionally  higher.   She asked  what the  committee should  be                                                               
aware of regarding performance metrics.                                                                                         
MR.  WALL replied  that this  was "both  a blend  of the  rate of                                                               
incidence and the  actual incidents itself and whether  or not it                                                               
was appropriate to restrain them."   He said that the big problem                                                               
resulting  from  the  surveys was  the  individual  instances  of                                                               
seclusion deemed  to be inappropriate  and outside  the standard.                                                               
He allowed  that there could  be an  indication for how  well the                                                               
institution was  doing with issues  of violence,  aggression, and                                                               
de-escalation  by comparison  to  the  rate on  the  charts.   He                                                               
pointed  out  that the  individualized  case  studies with  video                                                               
feedback  indicated what  had occurred  and whether  the response                                                               
was appropriate.                                                                                                                
3:26:43 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ pointed out that,  as safety and seclusion and                                                               
restraint problems were  some of the rationales  for initiating a                                                               
very controversial  approach to  changing the operations  at API,                                                               
it would be  helpful for the committee to be  presented with more                                                               
concrete  specifics for  absolute  appropriates and  how API  had                                                               
deviated from this norm.                                                                                                        
MR.  WALL replied  that the  reports and  survey findings  on the                                                               
website shared very  specific actions for what  happened and what                                                               
should have  happened.  Each  finding cited where the  action had                                                               
gone  outside the  regulatory  standard for  that  instance.   He                                                               
explained that  it was difficult,  as each instance  was weighed,                                                               
and each may have failed in a different regard to the standard.                                                                 
REPRESENTATIVE SPOHNHOLZ asked for a link to that report.                                                                       
3:27:58 PM                                                                                                                    
REPRESENTATIVE  JACKSON directed  attention  to  slide 14,  which                                                               
noted the  right to  be free  from physical  or mental  abuse and                                                               
corporal  punishment, as  well as  to be  free from  restraint or                                                               
seclusion,  and asked  about the  employee  options when  dealing                                                               
with a patient  acting out.  She questioned  whether the employee                                                               
could be put in danger without having these options.                                                                            
MR. WALL  expressed his agreement  with this dilemma.   He shared                                                               
that it was  very difficult to work with patients  at this acuity                                                               
level, as  they could  be dangerous.   He  said that  the primary                                                               
training  was based  on de-escalation,  adding that  the training                                                               
used at API was the Mandt System.   He read from slide 15, titled                                                               
"Seclusion &  Restraint at  API":  "Since  2011, there  have been                                                               
seven separate independent reports  indicating API uses seclusion                                                               
and restraint  inappropriately and/or  excessively."   He pointed                                                               
out  that  this  combination  caused   the  problem  in  specific                                                               
incidences.  He  shared an example of an individual  who was ill,                                                               
with  symptoms of  occasional violence.   He  pointed out  that a                                                               
vindictive  response, using  restraint as  a punishment,  was not                                                               
the correct way  to deal with the patient.   He read further from                                                               
slide  15:   "Since  2017,  API has  been  cited  at least  seven                                                               
separate times  for deficiencies including violations  of patient                                                               
rights and  use of seclusion and  restraint."  He added  that the                                                               
largest areas of deficiency were with seclusion and restraint.                                                                  
3:31:07 PM                                                                                                                    
REPRESENTATIVE CLAMAN asked  where to draw the  line, noting that                                                               
many of  the complaints were  in the  gray area, as  the incident                                                               
justified some  use of restraint,  and although it may  have been                                                               
for too long, it did not appear to go too far.                                                                                  
MR.  WALL  replied  "I  don't   believe  in  gray  areas  in  the                                                               
regulations for that particular issue.   It's a matter of patient                                                               
care and  human rights."   He emphasized  that having  someone in                                                               
restraints for  30 minutes longer  than necessary was wrong.   He                                                               
shared  an  example  of  a  patient who  was  verbally  loud  and                                                               
assaultive, and  the staff were  attempting to de-escalate.   The                                                               
patient  was asked  to  walk  on his  own  to  the seclusion  and                                                               
restraint room.   He posed whether this  was clinically necessary                                                               
as the patient was not violent  or a danger to himself or others.                                                               
He said  that this was  not within the  standards of care  if the                                                               
patient  was only  yelling; hence,  this was  a violation  of the                                                               
individual's rights.  "It's a clear line."                                                                                      
3:33:39 PM                                                                                                                    
REPRESENTATIVE CLAMAN said  that, although it may appear  to be a                                                               
clear line,  there may have  been prior behavior that  required a                                                               
"five-minute  time out,  a fairly  routine technique  that's used                                                               
not just  in psychiatric  hospitals, but parents  use it  all the                                                               
time with children."  He offered  his belief that this was a grey                                                               
area that could  be argued on both sides and  that it depended on                                                               
the  details of  the circumstance.   He  asked if  the incidences                                                               
mentioned in the reports could be argued on either side.                                                                        
MR. WALL acknowledged that there  were times when a patient would                                                               
voluntarily take  a time out to  calm down.  He  explained that a                                                               
grey  area was  reviewed by  a  CMS professional  looking at  the                                                               
situation  for   determination  whether   an  incident   broke  a                                                               
regulation, law, or procedure.  He stated:                                                                                      
     that's what  we're looking  at.  I  can look  at things                                                                    
     from the  outside a  certain way and  come up  with one                                                                    
     conclusion,  but,  when the  expert  on  the ground  is                                                                    
     telling you this is wrong,  and here's why, and it's in                                                                    
     the report, that's your final answer.                                                                                      
MR. WALL  declared that in-patient  psychiatric care was  a legal                                                               
issue.  He reported that the  ability for the state, or a doctor,                                                               
to  medicate an  individual against  their  will or  put them  in                                                               
restraint or  seclusion against their  will was a  difficult line                                                               
for attorneys,  judges, and care  providers to walk.   He offered                                                               
his belief  that the experts on  the ground had the  authority to                                                               
make the determination.                                                                                                         
3:37:15 PM                                                                                                                    
REPRESENTATIVE  CLAMAN  asked  whether  a  CMS  review  after  an                                                               
incident would  determine inappropriate behavior even  though the                                                               
finding  at  the time  had  determined  the  staff action  to  be                                                               
MR. WALL, in response, said that,  although he could not speak to                                                               
a  specific  incident,  in  his   personal  experience  this  had                                                               
occurred.   He pointed out  that, although there  were gradations                                                               
of an individual's  perception to an action,  in psychiatric care                                                               
the  authority rested  on the  surveyor's determination  of legal                                                               
compliance, clinical  appropriateness, or  the right thing  to do                                                               
for the patient.                                                                                                                
3:38:32 PM                                                                                                                    
REPRESENTATIVE JACKSON  asked about mental abuse  toward the care                                                               
giver by a  patient.  She opined  that there must be  a very high                                                               
turnover of staff.   She mused that  it must be a  very thin line                                                               
between protecting the patient or protecting the care giver.                                                                    
MR. WALL  expressed his agreement  that it was "a  very difficult                                                               
road  to walk."   He  reported that,  although there  was a  wide                                                               
range  of  symptomology for  individuals  with  a serious  mental                                                               
illness,  caregivers had  to change  their  perception to  better                                                               
understand this  was a  symptom of  the illness.   He  shared his                                                               
experience as a  psychiatric nurse.  He pointed out  that many of                                                               
the patients  at API had  been deemed non-competent and  were not                                                               
held accountable for their actions.                                                                                             
CO-CHAIR SPOHNHOLZ  expressed her concern that  API employees had                                                               
called the Anchorage Police Department  (APD) on patients, as, by                                                               
definition, admittance  into API determined a  lack of competence                                                               
and  accountability by  a patient.   She  asked if  API employees                                                               
were  no  longer contacting  APD  when,  in other  circumstances,                                                               
these  actions  by  patients  would   be  considered  assault  or                                                               
MR. WALL  replied that this  was another difficult line  to walk.                                                               
He declared  that, as all staff  had a right to  personal safety,                                                               
sometimes  the  police  were  called.   He  explained  that  this                                                               
becomes an issue when an individual  taken into custody had to be                                                               
charged with  a crime, but they  were sent back to  API for care,                                                               
as it  was the  only place  to send them.   He  acknowledged that                                                               
there had been  assaults on staff, and he allowed  that staff had                                                               
the right to call the police  and file charges even as the system                                                               
was designed to return the person to API for care.                                                                              
CO-CHAIR SPOHNHOLZ opined  that it was counter  intuitive to hold                                                               
a  person  accountable  after  their  civil  liberties  had  been                                                               
removed because  it had been  determined they were  not competent                                                               
to be free  and accountable.  She expressed that  the problem was                                                               
an underlying issue for not  having enough staff and enough well-                                                               
trained staff more  than an issue of culpability  for people with                                                               
mental illness  who had  been put in  the only  acute psychiatric                                                               
in-patient hospital in Alaska.                                                                                                  
MR. WALL  expressed his agreement.   He  stated that most  of the                                                               
API  staff  were  there  for  the  right  reasons,  to  care  for                                                               
individuals  with the  symptomology, and  they worked  at API  by                                                               
choice  as  they  enjoyed  working  with  this  population.    He                                                               
reiterated that  staff at API  had to maintain awareness  for the                                                               
potential for violence by the  patients.  He referenced slide 15,                                                               
"Seclusion &  Restraint at  API," and  directed attention  to the                                                               
just completed Ombudsman investigation, which read:                                                                             
     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;   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;  API  does not  consistently comply                                                                    
     with AS 47.30.825(d) or 42  CFR 482.13(e) in the use of                                                                    
     seclusion and restraint.                                                                                                   
MR. WALL  added that he was  looking forward to working  with the                                                               
Ombudsman for the findings on the report.                                                                                       
3:46:03 PM                                                                                                                    
MR. WALL moved on  to slide 16, "Safety at API."   He pointed out                                                               
the multiple  citations issued by Alaska  Occupational Safety and                                                               
Health (AKOSH) to  API:  in December 2014, 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;  in November                                                               
2017,  there   were  24  reportable  incidents   during  6  month                                                               
timeframe and API failed to  maintain its OSHA log and accurately                                                               
report  injuries  from 2014-2017.    He  pointed out  that  these                                                               
citations  were very  similar.   He  noted that  the 2015  report                                                               
found  that API  was  seriously  and "dangerously"  understaffed,                                                               
compensation was  too low,  and hiring  takes too  long. (Dvoskin                                                               
report.)  The 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).   In  September of  2018,  the injury  rates at  API                                                               
doubled and  on January 29,  2019, surveyors found  an unreported                                                               
"immediate jeopardy" incident.                                                                                                  
3:47:36 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ stated that the  issue for staffing at API had                                                               
been  recognized for  a very  long time,  noting that   this  was                                                               
underscored by the  Dvoskin report.  She pointed out  that the FY                                                               
20 proposal included a request for  an additional 80+ staff for a                                                               
total of  359 staff in  order to be staffed  at a safe  level for                                                               
both  patients and  staff; whereas,   the  proposal submitted  by                                                               
WellPath to  the State of  Alaska for  management of API  was for                                                               
only 276  staff.  She expressed  her concern for this  low number                                                               
of staff as currently API only  had a "few dozen fewer staff than                                                               
that on site."  She opined  that without a major infusion of both                                                               
training to  improve expertise and  staff capacity, it  would not                                                               
be possible for  API to reach a safe  and therapeutic environment                                                               
and return to a place of healing and recovery.                                                                                  
MR. WALL replied that, as  there were different methodologies and                                                               
curriculum trainings  by individual  agencies to  address certain                                                               
problems, the  staffing ratios changed  accordingly.   He offered                                                               
an  example  for  staffing  based on  different  protocols.    He                                                               
explained that there was a  therapeutic approach and well thought                                                               
out plan by  medical professionals for problem  solving, and each                                                               
clinic could  be a little  different.   He reported that  API had                                                               
not had  a comprehensive clinical  approach in a very  long time,                                                               
as  there  had   been  so  much  changeover   in  the  leadership                                                               
positions.  He stated that the  issue was not just for numbers of                                                               
staff, but  was about a comprehensive,  coherent, and appropriate                                                               
clinical approach  to a  problem for  which everyone  was trained                                                               
and in agreement.                                                                                                               
3:51:59 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ  expressed her  agreement  with  the need  of                                                               
consistency  in leadership  in  order to  develop  and execute  a                                                               
plan.  She noted that one  problem in leadership was a failure to                                                               
execute on  good plans  and good  work.   She offered  her belief                                                               
that the leadership at API  under former Director Duane Mayes had                                                               
done a lot of work to "put  in place plans which were designed to                                                               
improve safety."  She emphasized  that patient to staff ratio was                                                               
an  important  factor,  especially  when dealing  with  very  ill                                                               
patients.   She shared that  276 staff to  80 patients was  a 4.5                                                               
[staff] to [patients] ratio in a  24/7 facility.  She pointed out                                                               
that,  as  some  of  these staff  cleaned,  cooked,  and  handled                                                               
communications and security, not all  these staff were working in                                                               
direct care  for patients.  She  reported that with 359  staff at                                                               
API, as proposed  by former Director Mayes, the  ratio would drop                                                               
to  a 3.5  staff to  patient ratio.   She  pointed out  that some                                                               
patients  required one  on  one or  two  on one  care  in a  very                                                               
specific, "crisis  melt down situation," adding  that having more                                                               
personnel  was a  good thing  in  a facility  such as  API.   She                                                               
emphasized that the current  administration had initiated another                                                               
leadership  change  at  API, while  simultaneously  arguing  that                                                               
leadership consistency was important.   She opined that, instead,                                                               
it  may   have  made  sense   to  stick  with  the   Duane  Mayes                                                               
administration and  make the investment  of $44  million included                                                               
in the  previous FY  20 Walker  budget.   She declared  that this                                                               
would have  allowed consistency of delivery  with the opportunity                                                               
to execute a plan, resulting  in much lower conflict, crisis, and                                                               
controversy caused  by the introduction  of a  non-Alaska partner                                                               
to run API.                                                                                                                     
3:55:05 PM                                                                                                                    
MR. WALL presented  slide 17, "Staffing at API,"  a November 2011                                                               
WICHE (Western Interstate Commission  on Higher Education) report                                                               
and read:                                                                                                                       
     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                                                                    
MR. WALL offered his opinion that  these issues from 2011 had not                                                               
changed  to date  and  the  problems had  not  been  solved.   He                                                               
reported that  he and the  current commissioner came  into office                                                               
in  December [2018]  and discovered  issues  at API  "at a  point                                                               
when, literally, the ball was rolling  down the hill too fast and                                                               
we had to  stop it," they began to speak  with potential partners                                                               
about a  wide variety  of ways  to work  together to  solve these                                                               
issues, which  included consultants to work  on individual issues                                                               
for  a plan  of care,  consulting by  an administrative  services                                                               
organization   to   write   a   plan   of   correction,   partial                                                               
privatization,  and full  privatization.   He  stated that  these                                                               
talks  to  get  a  plan  of  correction  into  place  and  remain                                                               
certified with  CMS were  still ongoing up  to January  29, 2019,                                                               
when the survey  team returned and found  the immediate jeopardy.                                                               
At  that  point, they  decided  that  something  had to  be  done                                                               
immediately or  "the doors at  API are going  to be closed."   He                                                               
shared his understanding for the  public concern that the problem                                                               
was not that  dire, but "I can  assure you it was.   The doors at                                                               
API could have  closed, and frankly, still can."   He pointed out                                                               
that non-compliance for  the plans of correction  would result in                                                               
the loss of certification, accreditation, and license.                                                                          
3:58:29 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ  asked if, during  the exploration  of options                                                               
for operating  solutions, was there  any exploration  for staying                                                               
the course.                                                                                                                     
MR. WALL replied,  "yes" and he reiterated that they  had been in                                                               
the process of writing the  plan of correction with the remaining                                                               
API staff.                                                                                                                      
CO-CHAIR SPOHNHOLZ shared that many  people were very interested,                                                               
had  paid close  attention to  API, and  were very  aware of  the                                                               
safety issues.  She reported  that since a presentation about the                                                               
safety  issues  at  API  in  April [2018]  she  had  worked  with                                                               
partners to  secure an additional  20 PCNs [primary  care nurses]                                                               
and  other personnel  on-site, and  to offer  hiring bonuses  and                                                               
raises to  re-classify positions for appropriate  recruitment and                                                               
retention of staff,  in order to be competitive  with the market.                                                               
She  shared  that there  were  concerns  after the  Evans  Report                                                               
detailed that  the previous leadership  had not  been accountable                                                               
and transparent enough with the problems  at API and the need for                                                               
resolution.   She  reported  that Duane  Mayes,  a respected  and                                                               
credible manager, had been hired and  had been working on a "very                                                               
credible plan for turning around  API, which includes staffing at                                                               
the right levels, it includes letting  go of some staff that have                                                               
proven   to  be   less  than   meaningful  contributors   to  the                                                               
advancement of the mission of API."   She emphasized that she did                                                               
not understand the reason for a  change in leadership and a "pull                                                               
back" on the  budget, the investment, and  the strategies already                                                               
being  implemented  as  they  were  based  on  proven  models  of                                                               
leadership for getting  to the correct safety level at  API.  She                                                               
asked why there had been a change.                                                                                              
MR.  WALL replied  that it  was Mr.  Mayes' personal  decision to                                                               
move to  his current position, adding  that he was "good  at both                                                               
CO-CHAIR SPOHNHOLZ offered  her belief that the  desire "from the                                                               
very  beginning of  this administration  to  privatize API"  took                                                               
precedent over any other strategy to  invest in API.  She pointed                                                               
out that  the budget proposal  by the current  administration was                                                               
$33 million,  less than what  was needed to operate  the proposed                                                               
contract and  less than what  was needed  to ensure that  API was                                                               
safe.   She  expressed  her  concern that  this  would result  in                                                               
another debacle and asked how this proposal was any different.                                                                  
MR. WALL deferred to an  upcoming budget proposal to be presented                                                               
to the House  Health and Social Services Standing  Committee.  He                                                               
allowed that the  "emergent nature of what  occurred [on] January                                                               
29th is what drove a decision for change."                                                                                      
CO-CHAIR  SPOHNHOLZ  interjected  that  the  budget  issues  were                                                               
"pretty damn  important."  She  pointed to the  proposed contract                                                               
with Wellpath  [Recovery Solutions] which stipulated  that it was                                                               
subject  to appropriation.    If  the State  of  Alaska does  not                                                               
appropriate the full amount necessary  to operate API meeting the                                                               
contract, and the  contract obligated the State of  Alaska to $44                                                               
million in  FY 20, then  Wellpath could step back  from operation                                                               
of API at  any point in time.   She offered her  belief that this                                                               
could possibly set up the  state for another potential crisis, if                                                               
there was not "a rational strategy to execute."                                                                                 
MR. WALL  replied that this "can  be answered from both  sides of                                                               
the house"  during the upcoming budget  proposal presentation and                                                               
the Wellpath Recovery Solutions presentation.                                                                                   
4:02:57 PM                                                                                                                    
CO-CHAIR  ZULKOSKY  stated that,  although  there  was a  lot  of                                                               
passion  behind the  issue,  it was  important  to continue  with                                                               
respect from both sides of the table.                                                                                           
4:03:10 PM                                                                                                                    
REPRESENTATIVE JACKSON asked to finish the presentation.                                                                        
4:03:30 PM                                                                                                                    
MR.  WALL returned  to slide  18,  "Recruitment."   He said  that                                                               
there  had been  efforts to  increase recruitment  as there  were                                                               
several  vacant positions.   He  reported  that, as  it had  been                                                               
since July  2017 that API had  been at its full  80 bed capacity,                                                               
this was  used as the starting  point for reviewing the  net gain                                                               
in recruitment.   He reported that, since 2017, there  had been a                                                               
loss of 2  nurses, even as 12  nurses had been hired  in 2017, 12                                                               
more nurses had  been hired in 2018, and 2  nurses had been hired                                                               
in 2019.   He pointed  out that  this indicated a  turnover rate.                                                               
He stated that  recruitment for social workers  and mental health                                                               
clinicians was  much the same,  reporting that the hires  and job                                                               
losses had resulted in  a net gain of zero since  2017.  He added                                                               
that there  had been a  loss of  6 staff medical  providers since                                                               
2017,  which included  psychiatrists, as  well as  advanced nurse                                                               
practitioners   and   physician   assistants   with   psychiatric                                                               
4:05:40 PM                                                                                                                    
MR. WALL moved on to  slide 19, "Vacancies," reporting that there                                                               
was continue recruitment for state positions.                                                                                   
4:06:02 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ asked  how  many positions  at  API had  been                                                               
filled since he began his position in December [2018].                                                                          
MR. WALL  replied that  two nurses  had been  hired and  that the                                                               
lack  of  qualified  applicants   made  recruitment  lengthy  and                                                               
4:07:26 PM                                                                                                                    
REPRESENTATIVE CLAMAN  asked if any psychiatrists  had been hired                                                               
since  the two  psychiatrists at  API were  fired for  failure to                                                               
sign the governor's loyalty oath.                                                                                               
MR. WALL offered his understanding that no one had been hired.                                                                  
REPRESENTATIVE  CLAMAN  asked  if  there was  a  lawsuit  pending                                                               
regarding that firing.                                                                                                          
MR. WALL replied  that, although he was aware a  lawsuit had been                                                               
filed, he  did not know  the current status.   He shared  that he                                                               
understood  the  perspective  of   the  two  psychiatrists,  and,                                                               
although from  one perspective it  appeared to be a  firing, both                                                               
he and the  commissioner had met with the  two psychiatrists, had                                                               
asked  them to  stay,  and it  had  been the  choice  of the  two                                                               
psychiatrists to leave.                                                                                                         
REPRESENTATIVE CLAMAN  noted that  it was  the insistence  by the                                                               
administration on a  loyalty oath, offering his  belief that this                                                               
was "completely inappropriate."                                                                                                 
4:08:45 PM                                                                                                                    
CO-CHAIR ZULKOSKY reminded everyone  that all comments and follow                                                               
ups were to be requested through the chair.                                                                                     
4:08:59 PM                                                                                                                    
MR.  WALL  referenced the  pending  legal  issues with  financial                                                               
ramifications "hanging over  the State's head at this  time."  He                                                               
directed attention  to slide  20, "Forensic  Psychiatric Services                                                               
AS  12.47.010."   He reported  that when  a forensic  patient has                                                               
been  charged with  a  crime, and  if they  are  suspected to  be                                                               
incompetent  to stand  trial, they  are  sent to  API for  90-day                                                               
restoration increments  before re-evaluation.   He  reported that                                                               
the evaluation process  and restorative care did not  happen in a                                                               
timely  fashion.     He  declared  that,  although   API  had  an                                                               
obligation to  evaluate individuals in Department  of Corrections                                                               
facilities and  get them  into restorative care  if this  was the                                                               
appropriate course of  action, this was not happening.   He moved                                                               
to slide 21,  "Forensic Unit (Taku)" and shared  that daily there                                                               
were about 80  individuals waiting for the  evaluation process or                                                               
waiting for a  bed for restorative care to become  available.  He                                                               
shared  that   the  average  length   of  stay   for  individuals                                                               
inappropriately placed  in the Department of  Corrections waiting                                                               
for an  evaluation or restorative care  could be up to  136 days,                                                               
although these  individuals had  not been  convicted of  a crime.                                                               
He declared that  this created a liability for  the state, noting                                                               
that there  could be a  Department of Justice injunction  and the                                                               
state could be fined until the  problem was rectified.  He stated                                                               
that,  although  this was  a  financial  issue,  it was  also  an                                                               
ethical dilemma as  it was "wrong for us to  leave individuals in                                                               
prison for  that long of a  period of time without  treatment and                                                               
without conviction of  crime."  He reported that this  was one of                                                               
the  issues  at API  as  there  was only  a  10-bed  ward for  35                                                               
forensic  patients  and  the department  was  moving  rapidly  to                                                               
address this  issue.  He suggested  that the State could  find an                                                               
evaluator  to go  into the  prisons for  the evaluation  process,                                                               
noting that  there was the  same wait for felony  and misdemeanor                                                               
charges.   He pointed  out that  faster evaluations  could reduce                                                               
the  number  of people  in  prison.    He  added that  help  from                                                               
partners could  allow ad-hoc  forensic teams  to bring  more beds                                                               
on-line.  He explained the  staffing ratio for forensic units for                                                               
restorative care.                                                                                                               
4:14:53 PM                                                                                                                    
CO-CHAIR ZULKOSKY asked about the possible partners.                                                                            
MR. WALL  said that he went  to the ASHNA [Alaska  State Hospital                                                               
and  Nursing Home  Association] meeting  and "made  that plea  to                                                               
everybody."   He added  that more  evaluation and  treatment beds                                                               
had  been  designated statewide,  and  he  offered examples  from                                                               
around the state.                                                                                                               
4:16:05 PM                                                                                                                    
MR. WALL turned  to slide 22 "Legal Involvement,"  and said that,                                                               
although he  could not speak  directly to an active  lawsuit, the                                                               
jeopardy for liability was real  and ongoing and seemed to mirror                                                               
the progress in other states.                                                                                                   
REPRESENTATIVE CLAMAN asked for the meaning of "DLC."                                                                           
MR. WALL explained that this was the Disability Law Center.                                                                     
4:16:56 PM                                                                                                                    
MR. WALL moved on to  slide 23, "Civil Commitments AS 47.30.700."                                                               
He shared  that a problem  in many states, including  Alaska, was                                                               
for a  lack of psychiatric  beds.  In  a civil situation  in both                                                               
hospitals and  correctional institutions,  if a person  was found                                                               
to need  a bed for in-patient  care, yet there were  not any beds                                                               
available and the  patient was required to stay  in their current                                                               
setting  without the  necessary  care, then  the  state could  be                                                               
found liable.   He  pointed out that  the hospitals  were bearing                                                               
the brunt  of the workload and  the cost, which was  difficult to                                                               
MR. WALL shared  that there were several  case studies, including                                                               
slide  25,  "Washington,"  slide 26,  "Pennsylvania,"  slide  27,                                                               
"Utah," and slide 28, "Louisiana."   He directed attention to the                                                               
case  study in  Washington, an  on-going case  of liability.   He                                                               
reported that  there had been  a lawsuit with a  subsequent trial                                                               
in 2015 for constitutional rights, like  the issue in Alaska.  He                                                               
noted  that,  in July  2016,  there  was  a contempt  order  that                                                               
stated, after 7 days, the state  pay $500 per day per person, and                                                               
after 14 days the fine was to  be increased to $1,000 per day per                                                               
person.    He  reported  that  currently  in  the  Department  of                                                               
Corrections  there   were  about  80  people   included  in  this                                                               
category, which  carried a significant  financial liability.   As                                                               
of June 2018,  the fines in the State of  Washington exceeded $55                                                               
million,  which  did not  include  the  on-going treatment.    He                                                               
reported that  the settlement had  also required a change  by the                                                               
state  in five  substantive  areas, some  of  which required  the                                                               
building of new service facilities.                                                                                             
4:19:57 PM                                                                                                                    
MR.  WALL  directed  attention  to slide  29,  "The  decision  to                                                               
contract."   He shared the  goals for  seeking a contractor:   to                                                               
ensure  the safety  of  our staff  and patients;    to bring  the                                                               
hospital into rapid compliance with  regulatory authorities;  and                                                               
to prepare the  facility to increase its bed capacity  to 80 beds                                                               
by  1 July.   He  relayed that  following the  immediate jeopardy                                                               
finding in the  survey, there was discussion with  Wellpath for a                                                               
plan of  correction, which  had taken  more than  180 days  to be                                                               
accepted by both sides.  He  reported that the plan of correction                                                               
on the  findings in January  had already been accepted,  which he                                                               
called "a good  step in the right direction."   He stated that it                                                               
was  unprecedented for  the organization  not to  be de-certified                                                               
because  of  the immediate  jeopardy.    He  added that  CMS  was                                                               
working with the state.                                                                                                         
4:21:04 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ asked  about the process for  the selection of                                                               
Wellpath,  noting  that she  had  read  the supporting  documents                                                               
regarding the  three companies  contacted.  She  asked if  a non-                                                               
profit organization or  a local organization had  been willing to                                                               
partner  in  either a  turn  around  contract or  an  operational                                                               
contract at API.                                                                                                                
MR. WALL  replied that they  had not  found either, that  part of                                                               
the issue was  the necessary speed for a company  "to get experts                                                               
on the ground to assist us in particular in the area of safety."                                                                
CO-CHAIR  SPOHNHOLZ stated  that she  was "a  little confused  by                                                               
that."    She  reported  that  she  had  had  conversations  with                                                               
Providence Health  Systems, which had expressed  interest and had                                                               
offered,  to  operate API.    She  noted that  Providence  Health                                                               
Systems had asked for an  invitation to submit a proposal, should                                                               
an RFP (Request  for Proposal) be offered and had  reached out to                                                               
help in any way.  She  pointed out that Providence Health Systems                                                               
already had  a demonstrated track  record in the State  of Alaska                                                               
and was  already doing acute,  in-patient psychiatric  care right                                                               
across the  street from API.   She  offered her belief  that they                                                               
were a natural  partner and would be received more  warmly by the                                                               
MR.  WALL  shared  that  he  had also  spoken  with  the  CEO  at                                                               
Providence  Health  Systems,  and   acknowledged  that  they  had                                                               
expressed interest  in the past.   He  noted that the  detail for                                                               
what they could take on and  the speed with which they could move                                                               
were  also  parts   of  the  conversation.     He  expressed  his                                                               
willingness to  speak with Providence Health  Systems regarding a                                                               
CO-CHAIR   SPOHNHOLZ   said  that   she   could   not  find   any                                                               
documentation of any conversation  with Providence Health Systems                                                               
in December.  She asked if  there was a conversation with them in                                                               
December  specifically, and  whether  an outreach  phone call  to                                                               
Providence  Health Systems  had been  made when  the decision  to                                                               
bring in outside  expertise and capacity to help  operate API was                                                               
MR. WALL replied that he was  unsure of the specific date for his                                                               
contact with Providence Health Systems.                                                                                         
CO-CHAIR  SPOHNHOLZ asked  that  Mr. Wall  report  back with  the                                                               
date.   She said, "it  strikes me as unusual  to see a  series of                                                               
outreach to  organizations, none  of which  are operating  in the                                                               
State of Alaska or have, some  of which don't really have a track                                                               
record of  doing this specific  kind of  work."  She  pointed out                                                               
that,  as  Providence Health  Systems  was  already offering  in-                                                               
patient  psychiatric care  "right  across the  street, they  seem                                                               
like a  much more  natural partner  and one  which, I  think, the                                                               
community would be much more receptive to."                                                                                     
MR. WALL said that he would  provide the date, adding that he had                                                               
a phone  conversation with [Providence Health  Systems], although                                                               
he was not sure of the date.                                                                                                    
CO-CHAIR SPOHNHOLZ asked  if there was a concern  for the ability                                                               
of  Providence Health  Systems to  fully  staff API  "in a  quick                                                               
enough manner."   She asked why exploration  for this partnership                                                               
had not been pursued.                                                                                                           
MR.  WALL   offered  his  belief   that  the   conversation  with                                                               
Providence  revolved around  the  issues of  civil and  forensics                                                               
CO-CHAIR  SPOHNHOLZ asked  whether there  was any  way to  have a                                                               
hybrid model  and include a  working partnership  with Providence                                                               
Health Systems.                                                                                                                 
MR. WALL  opined that,  although there was  the possibility  of a                                                               
partnership  at some  level, the  response for  the emergency  on                                                               
January 29 had  driven the decision for a partner  "on the ground                                                               
and emergent control  as quickly as possible."   He reported that                                                               
Wellpath offered a  team of specialists that  would quickly cover                                                               
the  entire  spectrum  of  the  requirements  from  the  plan  of                                                               
correction  and would  address this  with  CMS.   He pointed  out                                                               
that,  although  many  of  the   API  leadership  positions  were                                                               
currently  vacant,  the  Wellpath team  of  specialists  mirrored                                                               
these leadership positions.   He added that  there had especially                                                               
been a focus  made toward the fulfillment for  the rapid response                                                               
CO-CHAIR SPOHNHOLZ  countered that  part of  the reasons  for the                                                               
vacancies  in the  leadership positions  at API  were because  of                                                               
decisions made  by the current  administration.  She  pointed out                                                               
that Providence Health Systems was  part of a large, seven-system                                                               
network, with mental and  behavioral health professionals working                                                               
across  the region.   She  suggested that  there could  have been                                                               
exploration for a  variety of operational models  which she would                                                               
have "received much more warmly."                                                                                               
MR.  WALL, in  response,  said  that he  spoke  to the  executive                                                               
director  of the  Providence mental  health  foundation and  that                                                               
there  would  be  another  conversation   for  a  discussion  for                                                               
4:27:20 PM                                                                                                                    
MR. WALL  presented slide 30,  "Immediate Jeopardy Finding."   He                                                               
reported that  the jeopardy  situation on January  29 had  been a                                                               
patient  on patient  assault and  that the  perpetrator had  been                                                               
placed on their own vacant ward.   He paraphrased from the slide,                                                               
which read:                                                                                                                     
     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.                                                                                                          
4:28:38 PM                                                                                                                    
CO-CHAIR ZULKOSKY  asked whether,  when a  finding was  found and                                                               
immediate steps were taken for  resolution, this finding would be                                                               
absolved and not impact accreditation.                                                                                          
MR. WALL  replied that "in some  cases it can, and  in some cases                                                               
it  doesn't."   He clarified  that the  discussion was  not about                                                               
accreditation, compliance  with a  set of  standards; but  it was                                                               
for  certification.   He explained  that there  had been  a legal                                                               
discussion with CMS  to determine whether API  was "in compliance                                                               
with  your  conditions  of  participation  legally  to  have  the                                                               
contract with  the federal government to  receive federal funds."                                                               
He stated  that this  was a different  relationship.   He offered                                                               
his belief that this was the  first immediate jeopardy at API and                                                               
that,  sometimes,  when  a  serious   deficiency  was  found  and                                                               
immediately responded  to, it  would fix the  problem.   He noted                                                               
that,  in this  case,  the  question was  now  for resolution  to                                                               
prevent recurrence.   He stated  that the lingering  effects were                                                               
for procedure and  how situations would be handled  in the future                                                               
as opposed  to the  immediate placement of  a patient  in another                                                               
4:30:16 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ referenced  the immediate  actions after  the                                                               
incident to  ensure safety and  opined that the  documentation of                                                               
the  incident had  not "made  it all  the way  through to  formal                                                               
reporting."  She asked if  this issue with documentation had been                                                               
identified by CMS as problematic.                                                                                               
MR. WALL, in  response, said that the most  egregious problem was                                                               
that the  perpetrator was  not removed from  the victim,  nor was                                                               
the victim assisted with any follow-up.   He declared that it was                                                               
not a matter of paperwork transfer.   He explained that "the lack                                                               
of paperwork transfer produced a lack of care in intervention."                                                                 
CO-CHAIR SPOHNHOLZ  noted that, in  her review of  the supporting                                                               
documents for the  procurement, she had found a  curiosity in the                                                               
timeline of  the immediate jeopardy  episode.  She  referenced an                                                               
e-mail dated January  22 in which Mr. Wall  described an upcoming                                                               
CMS  survey team  site visit  for  the following  week on  either                                                               
January 28 or  January 30.  She noted that  the seventh bullet of                                                               
this e-mail described this upcoming  event in the past tense, and                                                               
she asked if  there had been another immediate  jeopardy event to                                                               
which she was not aware.                                                                                                        
MR.  WALL replied  that he  was  not aware  of another  immediate                                                               
jeopardy event.                                                                                                                 
CO-CHAIR SPOHNHOLZ  shared that  she was somewhat  confused that,                                                               
in the e-mail  of January 22, an event was  described in the past                                                               
tense which did not happen until the following week.                                                                            
MR. WALL replied that he would need to review the timeline.                                                                     
CO-CHAIR SPOHNHOLZ said "it seemed unusual to me."                                                                              
4:32:15 PM                                                                                                                    
MR.  WALL  directed  attention to  slide  32  "Documents,"  which                                                               
listed a link to any requested documents.                                                                                       
4:32:50 PM                                                                                                                    
REPRESENTATIVE  CLAMAN asked  why  the  January emergency,  which                                                               
resulted  in the  immediate  introduction  of outside  management                                                               
with  a  short-term  contract  through  the  end  of  June,  also                                                               
resulted in a  non-competitive bid process for  the best services                                                               
starting July  31 with  this same outside  management group.   He                                                               
declared that he was "troubled by that."                                                                                        
MR.  WALL   replied  that   the  decision   had  been   made  for                                                               
privatization with an emergency provider  to solve the problem in                                                               
two phases.   Phase 1  had the aforementioned  three deliverables                                                               
attached.   He explained that  the decision to hire  a contractor                                                               
was done  under AS 47.32, and  he pointed to a  summary statement                                                               
issued  by the  Attorney General's  office explaining  the stance                                                               
from this statute.   He referenced the statute  which stated that                                                               
in cases of immediate harm or  immediate jeopardy to a patient in                                                               
the facility, the  commissioner could step in "in  a temporary or                                                               
permanent fashion."   He continued  to explain that  "after years                                                               
of  instability and  inability to  meet mission"  an organization                                                               
was brought in to stabilize,  bring the organization back to full                                                               
compliance,  and provide  care in  its full  capacity in  a short                                                               
period  of  time.    He  questioned  why,  after  this  had  been                                                               
accomplished, would the Department  of Health and Social Services                                                               
(DHSS) risk de-stabilizing that.   He explained that the contract                                                               
had been designed in two phases  to ensure meeting the mission in                                                               
the first phase  and to "roll into the stabilization  in the long                                                               
term in the  second phase."  He declared that  the desire of DHSS                                                               
was to  provide continuity and  stability for the system  and the                                                               
hospital over time.                                                                                                             
4:36:05 PM                                                                                                                    
REPRESENTATIVE  CLAMAN   pointed  out   that  the   decision  for                                                               
stabilization  with   only  one   option  to  provide   the  best                                                               
management  to  go  forward  was  made  between  January  29  and                                                               
February  8,  the date  of  the  signing  of the  contract  [with                                                               
Wellpath Recovery  Solutions].   He emphasized  that this  was "a                                                               
very, very  short period of  time."   He offered his  belief that                                                               
during this  time there had  not been any discussion  with groups                                                               
other than Wellpath Recovery Solutions.                                                                                         
MR. WALL,  in response,  said that this  decision was  made after                                                               
determination  for  the  speed at  which  other  providers  could                                                               
arrive.   He  declared that  "the conversation  was not  small or                                                               
quick  in the  commissioner's  office" and  he  listed the  other                                                               
participants in the decision making  for how to proceed, what was                                                               
the best course  of action, and what best  protected and provided                                                               
care  for the  patients  and staff.   He  stated,  "that was  the                                                               
decision that was made."                                                                                                        
REPRESENTATIVE  CLAMAN asked  for the  date on  which the  formal                                                               
decision was made  to move forward with a  single source contract                                                               
and  not to  go through  a procurement  process for  the services                                                               
beginning on July 1.                                                                                                            
MR. WALL  said that he  would get that  date.  He  explained that                                                               
the  situation   appeared  very  similar  to   another  immediate                                                               
jeopardy issue  in Alaska, in which  the commissioner [Department                                                               
of Health and Social Services]  had intervened in this exact way,                                                               
hence the  decision was  made at  that point.   He  reported that                                                               
there were "a  lot of long hours and much  discussion" before the                                                               
decision was made.                                                                                                              
4:38:59 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ  opined that  the  primary  criteria for  the                                                               
selection of  Wellpath Recovery Solutions  was "their  ability to                                                               
come in and take over operations  of API immediately."  She asked                                                               
if there were other criteria reviewed, as well.                                                                                 
MR.  WALL paraphrased  the  criteria listed  on  slide 31,  which                                                               
     Was available immediately;                                                                                                 
    Had    specific   inpatient    psychiatric   experience                                                                     
     including both civil and criminal commitments;                                                                             
      Has a team of nationally recognized experts that has                                                                      
     the experience and track record to bring noncompliant                                                                      
     hospitals back into compliance rapidly.                                                                                    
MR.  WALL  declared  that  this  was  a  very  difficult  set  of                                                               
expertise to find.                                                                                                              
CO-CHAIR  SPOHNHOLZ   reported  that  about  23   other  national                                                               
corporations performed this type of work.  She declared:                                                                        
     it seems highly  unlikely that this is  the only choice                                                                    
     we could  have pursued,  and that it's  highly atypical                                                                    
     to take a specific emergency  event to issue a contract                                                                    
     which  essentially  obligates  the state  to  over  $88                                                                    
     million  in   contract  without  any   transparency  or                                                                    
     competition  in the  process,  particularly when  we're                                                                    
     talking  about  operating  an  institution  that  cares                                                                    
     for...  our  most vulnerable  people  in  the State  of                                                                    
CHAIR SPOHNHOLZ expressed concern that  there was not a review of                                                               
other  providers   when  considering  this   extremely  important                                                               
responsibility with API.                                                                                                        
MR. WALL acknowledged  the concern and reiterated  that, as there                                                               
had been  previous discussion with  three organizations,  when it                                                               
became necessary to move rapidly  when the immediate jeopardy was                                                               
discovered,  they were  aware  that  Wellpath Recovery  Solutions                                                               
could be there quickly.                                                                                                         
CO-CHAIR  SPOHNHOLZ  offered her  belief  that  it was  extremely                                                               
atypical to issue  a sole source contract for a  project that was                                                               
so important.   She pointed out  that in the public  sector there                                                               
were  rules  for transparency  in  the  competitive bid  process.                                                               
These required  review of  a broad  range of  performance metrics                                                               
and financials before  undertaking a contract of this  size.  She                                                               
pointed  out that  the only  performance  metric was  for API  to                                                               
operate at full capacity and  remain accredited.  She opined that                                                               
there was no  incentive in the contract to ensure  a safe, trauma                                                               
informed, and therapeutic  environment.  She asked  that Mr. Wall                                                               
address the  concern that  there were  not any  other performance                                                               
metrics in the contract.                                                                                                        
MR. WALL  reported that the  three metrics in the  contract were:                                                               
to  ensure the  safety and  security  of staff  and patients;  to                                                               
bring  the  organization  back  into  rapid  compliance;  and  to                                                               
prepare for  the opening  of all 80  beds by July  1.   He stated                                                               
that  those metrics  were  in the  contract,  adding that  safety                                                               
meant  a reduction  of assaults,  seclusion, restraint,  and harm                                                               
and that those needed to be  evident.  He explained that bringing                                                               
the organization back into compliance  with the regulatory bodies                                                               
meant that  it was necessary to  have the plans of  correction in                                                               
place  and  have  them  as   an  accepted  practice  to  all  the                                                               
regulatory bodies.  He added that  it was also necessary to bring                                                               
the organization back to full capacity.                                                                                         
CO-CHAIR SPOHNHOLZ stated that these  agreements should be in the                                                               
contract and  possibly in a  service level agreement.   She asked                                                               
if there was a service level agreement with the contract.                                                                       
MR. WALL  said that the  second phase  of the contract  was being                                                               
worked  as  they  moved  forward, and  that  the  contract  would                                                               
"definitely have one."                                                                                                          
CO-CHAIR  SPOHNHOLZ  commented  that, typically,  in  the  public                                                               
sector with  such an important  responsibility in caring  for the                                                               
most vulnerable and  the use of state resources,  it was required                                                               
to have  transparency in  this entire process.   She  stated that                                                               
the details  of a  contract should be  determined earlier  in the                                                               
process,  with a  competitive  bid process.    She expressed  her                                                               
concern whether this  was the best possible  product resulting in                                                               
the best possible  care for the patients at API.   She emphasized                                                               
that "the striking lack of  transparency in this process concerns                                                               
4:45:38 PM                                                                                                                    
REPRESENTATIVE  JACKSON asked  whether  Phase 2  would offer  the                                                               
option for other partnerships.                                                                                                  
MR. WALL  replied that Department  of Health and  Social Services                                                               
and  Wellpath were  "definitely moving  towards partnership  with                                                               
other  organizations."   He added  that  this could  not be  done                                                               
without partnerships and "we will continue to seek them."                                                                       
REPRESENTATIVE JACKSON  asked to verify that  Wellpath would work                                                               
with  other institutions  and organizations  to  ensure that  the                                                               
patients at API would get everything they needed.                                                                               
MR. WALL replied that there  were many partners throughout Alaska                                                               
to ensure in-patient psychiatric care,  although API was the most                                                               
visible and  the most  volatile piece  of this  care system.   He                                                               
stated   that   the   partnership  "that   cares   for   patients                                                               
appropriately  across  the state  needs  to  be  built in  a  ...                                                               
broader capacity."                                                                                                              
4:47:24 PM                                                                                                                    
CO-CHAIR ZULKOSKY directed attention  to the procurement document                                                               
which indicated a  June or July time frame for  the Department of                                                               
Health and Social Services to  assess whether to continue to work                                                               
with Wellpath.   She  shared that  her discussions  with Wellpath                                                               
executives indicated that, for a  proper transition, the decision                                                               
would need to  happen by mid-April.  She offered  her belief that                                                               
it  was not  possible  to accomplish  all  the agenda  milestones                                                               
outlined  for  Wellpath  by  this   time.    She  asked  how  the                                                               
department was handling this.                                                                                                   
MR. WALL replied  that the evaluation for  whether Wellspring had                                                               
met the  terms of their contract  needed to be made  by April 15.                                                               
If  Wellspring was  going  to be  successful in  Phase  2 of  the                                                               
contract, it would be necessary to  have the staffing in place to                                                               
meet the terms of the contract.   He stated that Wellspring would                                                               
need to  begin hiring  and licensing  staff prior  to June  30 in                                                               
order to move  into the second phase.  He  explained that some of                                                               
the  dates were  for  hiring  and some  were  for the  evaluation                                                               
CO-CHAIR ZULKOSKY asked  about the date for  Department of Health                                                               
and Social Services  to make a determination  whether to continue                                                               
the contract with Wellpath.                                                                                                     
MR. WALL replied, "April 15."                                                                                                   
CO-CHAIR ZULKOSKY expressed  her concern for such  a large amount                                                               
of  work in  such a  short  period of  time, and  that "it  seems                                                               
incongruent for the  department to be able to make  a decision by                                                               
then."   She  asked  for an  explanation to  the  logic for  this                                                               
MR. WALL echoed  her concern for the workload,  noting that there                                                               
was a  tremendous amount of  work to be  done prior to  April 15.                                                               
He declared "the reality  is we need to have a  point at which we                                                               
can  evaluate  the  progress  towards   meeting  the  goals"  and                                                               
contractual obligations  prior to  a date  for Wellpath  to build                                                               
the necessary  staff.  He  noted that  the decision point  had to                                                               
allow Wellpath enough time to  hire, license, and place staff and                                                               
ensure meeting the goals.                                                                                                       
CO-CHAIR ZULKOSKY opined  that the decision to  move forward with                                                               
Wellpath had  been made  regardless of the  outcome of  the goals                                                               
outlined in the procurement documents.                                                                                          
MR.  WALL added  that the  contract also  included a  30-day out-                                                               
clause  which he  described as  an evaluation  point between  the                                                               
State of  Alaska and the contractor.   He said that  there was an                                                               
on-going consistent  evaluation of progress performed  on a daily                                                               
and weekly basis.   He reported that there were  a complex number                                                               
of  plans of  correction and  points on  each of  those plans  of                                                               
correction  that   needed  to  be   fixed  and  addressed   in  a                                                               
substantive way between  now and the time  stated for compliance.                                                               
He  explained that,  as  each individual  requirement  had to  be                                                               
tracked, "there's  a heavy  lift of  work to be  done."   He said                                                               
that for  the goals to  be attained, it  was necessary to  have a                                                               
period of  time for commitment  to allow for staffing  to provide                                                               
the care necessary to move forward.                                                                                             
4:52:31 PM                                                                                                                    
REPRESENTATIVE  TARR expressed  her  discomfort  as the  decision                                                               
point  was too  early  in  the process  to  be  able to  evaluate                                                               
success,  which   prevented  Department  of  Health   and  Social                                                               
Services from looking at other  opportunities.  She said this did                                                               
not allow enough time "to see if  this is the right thing to do."                                                               
She pointed out  that there was proposed  legislation to prohibit                                                               
the privatization of  API, as well as the budget  issue, and that                                                               
neither of  these would be accomplished  prior to April 15.   She                                                               
opined that this  would put more pressure on  an already stressed                                                               
situation, which could be unproductive and uncomfortable.                                                                       
MR. WALL  said that he  also felt  an immense amount  of pressure                                                               
for the  complexities of  moving forward in  this situation.   He                                                               
shared  that, as  the  perspective was  for  a mutual  commitment                                                               
between the state  and the contractor, the  contract was designed                                                               
in  a  way  for the  state  to  commit  to  the contractor  on  a                                                               
substantive level  so the contractor  could commit  the resources                                                               
to build success into the system.   He stated that a half-hearted                                                               
approach  was "doomed  for failure."    He pointed  out that  the                                                               
liability for  the state with  this issue required  a significant                                                               
investment of time  and money moving forward.  He  added that the                                                               
state  continued   to  build  relationships  with   partners  and                                                               
continued  to  look  for  solutions,  noting  that  the  contract                                                               
offered a  30-day window for evaluation.   He said that  April 15                                                               
was  a  turning  point  which   allowed  the  ability  to  commit                                                               
investment of resources, while also allowing the 30-day window.                                                                 
4:56:12 PM                                                                                                                    
REPRESENTATIVE PRUITT  reminded that there was  a specific reason                                                               
for the July 1 date in Phase 2.                                                                                                 
MR. WALL explained  that the state was  under provisional license                                                               
regarding the issues  at API until June 30.   He pointed out that                                                               
after that date  the problems did not go away  as there was still                                                               
an  iterative process  for  correction to  many  years' worth  of                                                               
REPRESENTATIVE   PRUITT   highlighted   that   there   had   been                                                               
recognition  of a  problem with  API during  the past  year.   He                                                               
reported that  this had not  been a  snap decision, but  that the                                                               
January 29  issue had forced immediate  action.   He  stated that                                                               
there  had been  a disservice  to the  people being  served.   He                                                               
declared  that  we  were  not  serving the  people  who  API  was                                                               
supposed  to  be   serving.    He  said  that  it   was  a  moral                                                               
responsibility to take action immediately.                                                                                      
MR.  WALL expressed  his agreement  that there  had been  warning                                                               
about this  crisis, which could not  be addressed by a  small and                                                               
normal  change.   He  acknowledged  that there  was  a moral  and                                                               
financial crisis  and that  it was his  obligation to  meet both.                                                               
He relayed  that "sometimes  you call  the shot  and you  do your                                                               
best as a group, as a team, to answer a specific need."                                                                         
5:00:43 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ   expressed  her  agreement   that  something                                                               
seriously needed  to be done at  API, and she asked  to return to                                                               
the process for how to address  the issues.  She pointed out that                                                               
there had  to be  a written feasibility  study when  bringing any                                                               
changes  to   the  collective   bargaining  agreement   with  the                                                               
employees.   She reported  that there had  been an  earlier study                                                               
for  privatization  which  had  found that  there  were  not  any                                                               
savings or better outcomes, so there  was a decision to "stay the                                                               
course."  She asked about  the status of the required feasibility                                                               
MR.  WALL  said  that  there  was intent  to  have  the  previous                                                               
feasibility  study updated.   He  pointed out  that it  had first                                                               
been  done in  2016 and  published in  2017, and  that "much  has                                                               
changed since then."   He noted that the beds  were closed at API                                                               
after  that study.    He said  that they  intended  to have  this                                                               
completed  study within  the 30-day  contractual obligation  with                                                               
the partner unions.                                                                                                             
CO-CHAIR SPOHNHOLZ asked  if this was a realistic  time frame and                                                               
would it affect the deadline for a decision point with Wellpath.                                                                
MR.  WALL expressed  his  agreement that  it  was an  "incredibly                                                               
tight turn around."  He  reported that the organization which had                                                               
previously done  the feasibility study  felt they could  "turn it                                                               
around quickly."                                                                                                                
5:04:07 PM                                                                                                                    
REPRESENTATIVE TARR expressed agreement  that this was an ongoing                                                               
problem.   She stated  her hope  that a  lesson had  been learned                                                               
with the forced resignation under  partisan political pressure of                                                               
two  of the  top  employees  at API,  which  had exacerbated  the                                                               
problem at a critical time.   She emphasized that, as it was hard                                                               
to attract  and retain these  highly skilled  positions, politics                                                               
should not be played with those important positions.                                                                            
^PRESENTATION:  WELLPATH RECOVERY SOLUTIONS                                                                                   
           PRESENTATION:  WELLPATH RECOVERY SOLUTIONS                                                                       
5:05:47 PM                                                                                                                    
CO-CHAIR  ZULKOSKY  announced that  the  next  order of  business                                                               
would  be   a  PowerPoint   presentation  by   Wellpath  Recovery                                                               
5:06:23 PM                                                                                                                    
JEREMY BARR,  President, Wellpath  Recovery Solutions,  said that                                                               
he  would  provide  information about  Wellpath  and  provide  an                                                               
update on the progress thus far at API.                                                                                         
DR.  KEVIN ANN  HUCKSHORN, Senior  Consultant, Wellpath  Recovery                                                               
Solutions,  paraphrased from  slide  1 "What  We Believe,"  which                                                               
        Persons suffering from mental illness can and do                                                                        
      Caregivers first priority is to support recovery of                                                                       
     the patients they serve                                                                                                    
         Patient care should be individualized, trauma-                                                                         
     informed, and evidence-based                                                                                               
        Staff are entitled to the training, support and                                                                         
     guidance they need to be effective                                                                                         
     Staff and patient safety are interrelated                                                                                  
MR.  BARR moved  on to  slide 2,  "Who We  Are," and  stated that                                                               
Wellpath was  a health  care company providing  health care  in a                                                               
variety  of  public  settings.     He  reported  that  they  were                                                               
organized into three operating divisions:   providing health care                                                               
to local government entities; providing  health care to state and                                                               
federal  entities;  and  this  entity  at  API,  specializing  in                                                               
providing inpatient  psychiatric and  residential treatment.   He                                                               
added  that this  division  operated  at 13  sites  in 8  states,                                                               
served about 2,700 persons, and had about 3,000 employees.                                                                      
MR.  BARR shared  slide  3 "Division  Overview"  and stated  that                                                               
Wellpath had experience with a  wide range of patient populations                                                               
who  had been  involuntarily  committed to  a  term of  treatment                                                               
either through a  civil or a forensic court process.   He pointed                                                               
out  that   each  of   the  programs   promoted  trauma-informed,                                                               
evidence-based, and individualized patient  care which was person                                                               
centered  and focused  on individual  strengths  to help  empower                                                               
individuals  to  recover.   He  moved  on  to slide  4,  "Current                                                               
Operations," which depicted the  12 operations currently operated                                                               
by Wellpath.                                                                                                                    
MR.  BARR shared  slide 5,  "South Florida  State Hospital,"  and                                                               
reported that Wellpath  had a more than  20-year partnership with                                                               
the Department of  Children and Families in Florida  for this 41-                                                               
bed hospital.                                                                                                                   
5:11:09 PM                                                                                                                    
DR. HUCKSHORN added that there  had been a virtual elimination of                                                               
restraint  and seclusion  at that  facility.   She reported  that                                                               
restraint and  seclusion had been  a national issue in  1998, and                                                               
the U.S. Congress had called  hearings for discussion.  She spoke                                                               
to  the  success  of  the  public-private  partnership  of  South                                                               
Florida Hospital, noting that the  conflict and violence had been                                                               
greatly  reduced  and  the  patient  participation  in  treatment                                                               
programs  had  increased.    She   stated  that  there  was  more                                                               
effective  work  toward patient  discharge.    She reported  that                                                               
there  was  98  percent  patient   satisfaction  as  measured  by                                                               
confidential surveys and grievances.                                                                                            
5:14:42 PM                                                                                                                    
REPRESENTATIVE  TARR  directed  attention to  the  Florida  Civil                                                               
Commitment  Center referred  to  on  slide 4  and  asked why  the                                                               
website listing  was for  Correct Care  Recovery Solutions.   She                                                               
asked about the relationship between the two companies.                                                                         
5:15:15 PM                                                                                                                    
MR. BARR, in  response to Representative Tarr,  explained that it                                                               
was the same  legal entity although there had been  a name change                                                               
from  Correct  Care  Recovery  Solutions,  now  renamed  Wellpath                                                               
Recovery Solutions.                                                                                                             
5:15:36 PM                                                                                                                    
MR. BARR shared slide 6,  "Bridgewater State Hospital," and spoke                                                               
about  the history  of the  hospital prior  to its  management by                                                               
Wellpath in 2017.                                                                                                               
5:16:55 PM                                                                                                                    
DR.  HUCKSHORN  detailed  her involvement  with  the  Bridgewater                                                               
State Hospital program beginning in 2017.                                                                                       
5:18:23 PM                                                                                                                    
DR.  HUCKSHORN turned  to slide  7,  "Treatment Philosophy,"  and                                                               
stated  that the  "treatment philosophy  basically  lays out  our                                                               
values" and  that these  values became  the template  to measure.                                                               
She paraphrased from the slide, which read:                                                                                     
     Recovery    model    ?     Trauma-informed    care    ?                                                                    
     Interdisciplinary,   holistic  approach   ?  Effective,                                                                    
     evidence-based   programs  ?   Culturally  relevant   ?                                                                    
     Integrated  treatment   of  co-occurring   disorders  ?                                                                    
     Collaborative safety planning                                                                                              
DR. HUCKSHORN  continued with slide  7, stating that  the patient                                                               
had to be  included in the development and  the implementation of                                                               
the  plan of  care.   She  added that  when untreated,  psychosis                                                               
patients lose  brain function which  would not be regained.   She                                                               
said that  it was necessary  to respect cultural  differences and                                                               
viewpoints.  Medicine  has moved from "let's hope  this works" to                                                               
evidence and results-based  practices.  She reported  on the loss                                                               
of  fundamental civil  rights of  American citizens  who enter  a                                                               
psychiatric hospital,  which makes  them completely  dependent on                                                               
staff to meet  their needs.  She declared that  an environment of                                                               
care,  with respect  and dignity,  was critical  to a  successful                                                               
treatment process.  She concluded  by stating that safety was the                                                               
responsibility  of everyone,  from the  CEO through  the janitor,                                                               
and  included  the  people  served.    She  stated  that  it  was                                                               
necessary to create  a safe community of  people working together                                                               
to keep everyone safe.                                                                                                          
5:26:27 PM                                                                                                                    
DR.  HUCKSHORN shared  slide 8,  "Minimizing Abuse,  Neglect, and                                                               
Exploitation."  She paraphrased from the slide, which read:                                                                     
     Zero  tolerance for  abuse,  neglect, and  exploitation                                                                    
     including  sexual  misconduct  ?  Allegations  promptly                                                                    
     reported  and   referred  for  investigation   ?  Staff                                                                    
     receive  training  when  they are  hired  and  annually                                                                    
     thereafter  ?  Patient  Advocate and  Peer  Specialists                                                                    
     ensure  patients have  opportunities  to safely  report                                                                    
5:28:39 PM                                                                                                                    
DR.  HUCKSHORN moved  on to  slide  9, "Culture  of Safety,"  and                                                               
stated that this  was the number one priority for  Wellpath.  She                                                               
highlighted that  it meant  immediate failure  if "the  people we                                                               
serve do not  feel safe in the environment  where they're getting                                                               
treatment, and we also fail if our  staff do not feel safe."  She                                                               
paraphrased from the slide, which read:                                                                                         
     Communication  ?  Collaboration   ?  Safety  Surveys  ?                                                                    
     Trainings ? Quest Rounds ? MANDT System                                                                                    
5:31:58 PM                                                                                                                    
MR.  BARR  added  that with  inherently  unpredictable  behaviors                                                               
associated  with  these  populations,   there  will  be  critical                                                               
incidents so  that reporting  and documenting  becomes paramount.                                                               
He  shared  that   Wellpath  had  invested  in   a  program  that                                                               
documented incidents and allowed for  the data to be compared and                                                               
assessed for appropriate triage.                                                                                                
5:33:12 PM                                                                                                                    
DR. HUCKSHORN  moved on to  slide 10, "Restraint  and Seclusion,"                                                               
which she  deemed to be  "quite close to  my heart."   She shared                                                               
her background  and referenced an  incident in which a  child had                                                               
died in  restraint in Hartford,  Connecticut.  That death  led to                                                               
hearings  in the  U.S. Congress,  resulting  in a  change in  the                                                               
rules and regulations for the  use, monitoring, and documentation                                                               
of  seclusion  and  restraint.     She  and  her  colleagues  had                                                               
developed  evidence-based  practice   known  as  "the  six-course                                                               
strategies to prevent conflict and  violence in behavioral health                                                               
in-patient  settings."    She  pointed   out  that  many  of  the                                                               
strategies were a  result of learnings from her  work at Wellpath                                                               
and  that the  program  had  since been  implemented  in all  the                                                               
Wellpath facilities.  She directed  attention to the graph on the                                                               
slide  which  depicted  "Hours of  Restraint  Per  1,000  Patient                                                               
Hours"  in  five  different  facilities,   noting  that  the  two                                                               
Wellpath  facilities   scored  much  better  than   the  national                                                               
aggregate.   She  reported that  Wellpath strongly  believed that                                                               
seclusion and  restraint was  dangerous, it  could hurt  and kill                                                               
people, and it  was traumatizing; hence, this  action was avoided                                                               
at all costs.                                                                                                                   
5:36:20 PM                                                                                                                    
DR.   HUCKSHORN,  in   response   to  Representative   Spohnholz,                                                               
clarified that this was the  Nashgood [indisc] Research Institute                                                               
Weighted  Average   for  200  of   the  Joint   Commission  State                                                               
5:36:36 PM                                                                                                                    
REPRESENTATIVE TARR asked  how Wellpath had been  able to achieve                                                               
such a  contrast to other  facilities.  She  asked if this  was a                                                               
result  of more  professionalized treatment  for the  individuals                                                               
with a serious mental illness.                                                                                                  
5:37:46 PM                                                                                                                    
DR.  HUCKSHORN answered  "it's complicated,  because violence  is                                                               
complicated,  and  has  multiple  variables."   She  offered  her                                                               
belief  that the  only way  for  success was  with a  significant                                                               
culture change  that begins at  the very top of  the organization                                                               
with  specific policy  statements  from senior  leadership.   She                                                               
reported that  there had  been a decision  to only  use restraint                                                               
and  seclusion "in  the face  of imminent  danger and  as a  last                                                               
resort."   She added that no  one would be left  in seclusion and                                                               
restraint,  and  after the  incident,  there  would be  "rigorous                                                               
debriefing."    She  stated  that  it  was  necessary  to  create                                                               
environments of care and avoid conflicts  in order to not have to                                                               
use seclusion and  restraint.  She spoke about  the necessity for                                                               
the  shifting of  "unwritten rules"  because so  many fundamental                                                               
human  rights were  stripped from  individuals when  they entered                                                               
the  hospital.   She  relayed  that it  was  important to  always                                                               
remember that  "we are much more  similar to the people  we serve                                                               
than we  are not."  She  reported that Wellpath did  "really good                                                               
risk  assessments" for  trauma  history, treatment  intervention,                                                               
remission  history,  anger  management, sensory  modulation,  and                                                               
violence risk.   She spoke  about immediate safety  planning with                                                               
new  patients.   She  noted  that  there  was also  rigorous  de-                                                               
briefing to avoid future issues.                                                                                                
5:43:44 PM                                                                                                                    
MR.  BARR, in  response to  Representative Claman,  explained the                                                               
lines on  the graph  on slide  10, noting that  the grey  and the                                                               
green lines disappeared on the graph as they were zero.                                                                         
5:44:46 PM                                                                                                                    
MR. BARR introduced slide 11, "What  Does Success Look Like?"  He                                                               
paraphrased the slide, which read:                                                                                              
     Compliance with all regulatory  agencies ? Services for                                                                    
     up  to   80-beds  ?  Increase  staffing   complement  ?                                                                    
     Improvements in  the therapeutic milieu ?  Reduction in                                                                    
     grievances  ?  Improved  linkages within  continuum  of                                                                    
     care  ?   Reduction  of   seclusion  and   restraint  ?                                                                    
     Reduction  in  assaults   ?  Community-based  Governing                                                                    
     Board ? Improved  communications and collaboration with                                                                    
MR.  BARR said  that they  had  met with  stakeholders to  better                                                               
understand and  strategize for  how to  integrate and  operate in                                                               
5:48:53 PM                                                                                                                    
REPRESENTATIVE  CLAMAN noted  that  Wellpath  was recommending  a                                                               
community  based governing  board, and  asked if  there would  be                                                               
proposed  legislation from  the administration  for consideration                                                               
of this.                                                                                                                        
5:49:13 PM                                                                                                                    
MR.  WALL clarified  that  there were  existing  by-laws for  the                                                               
hospital and that the governance  board, and its make-up was part                                                               
of  those by-laws.    He  reported that  this  make-up was  being                                                               
amended to  match the  Wellpath message and  he offered  to share                                                               
the board members.                                                                                                              
REPRESENTATIVE CLAMAN  suggested that  there had  been a  loss of                                                               
confidence  in  the  process,  and the  absence  of  a  community                                                               
governing board being actively involved in  API.  He asked if the                                                               
administration  would  consider  putting  this  into  statute  to                                                               
specify its continuing existence and  who served on the board, so                                                               
this would not be lost in regulation.                                                                                           
MR. WALL expressed,  "we could certainly look  at doing something                                                               
like that.  I'm not sure what all that would require."                                                                          
5:50:44 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ acknowledged  that they had checked  "a lot of                                                               
boxes for  me in terms  of talking about the  way it is  that you                                                               
treat the  people that  you care  for, the  way that  you develop                                                               
your staff, you build your  team," although there were still some                                                               
pieces missing,  which included an  external governing  board and                                                               
clear standards for performance.   She asked if Wellpath would be                                                               
willing to amend the contract  to include performance metrics and                                                               
5:52:21 PM                                                                                                                    
MR. BARR  replied, "yes, absolutely."   He relayed that  the idea                                                               
for associated performance measures and  oversight in the form of                                                               
audits were welcome.                                                                                                            
5:53:01 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ  shared that  there was an  additional concern                                                               
for how the  State of Alaska can be confident  about the Wellness                                                               
health  and safety  record.   She  reported that  a quick  Google                                                               
search on the  web revealed some concerning  reports and lawsuits                                                               
with  findings.   She listed  some of  these findings  to include                                                               
trafficking of  medications and overmedication of  patients.  She                                                               
pointed out  that these preceded  Wellpath in its  reputation and                                                               
brought concern  when "handing over  care of our  most vulnerable                                                               
people."  She asked for a response on the record.                                                                               
5:54:14 PM                                                                                                                    
MR.  BARR addressed  the trafficking  of medications  and pointed                                                               
out  that this  had been  by a  contracted pharmacy  relationship                                                               
with  a   consulting  agreement,   and  the  contract   had  been                                                               
immediately  terminated.   Subsequently,  the  pharmacy role  was                                                               
brought  in-house.   Regarding quality  of care,  he stated  that                                                               
these were  challenging health care environments  with occasional                                                               
adverse  outcomes.   In 95  percent of  the time,  these outcomes                                                               
resulted from  a single individual  acting outside of  policy and                                                               
procedure.  He reported that  there had been an immediate action,                                                               
with the  individual placed on  administrative leave  without pay                                                               
while there was an investigation  by their Office of Professional                                                               
Responsibility  for determination.   Pending  the results  of the                                                               
investigation,  there was  a  range  of progressive  disciplinary                                                               
options,  up to  and  including termination.    He continued  and                                                               
explained that  there was a  longer-term action to  address these                                                               
situations in order to minimize  the likelihood for a recurrence.                                                               
He  reported  that  there  had  been  discrepancies  between  the                                                               
documentation  and  the  video   footage,  so  they  invested  in                                                               
technology  that   allowed  tracking  for  accountability.     He                                                               
described the technology.                                                                                                       
5:58:35 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ applauded their use  of a systemic strategy to                                                               
address safety,  although it appeared  that there could  still be                                                               
challenges  remaining.    She  asked  them  to  address  the  six                                                               
wrongful death  lawsuits at  the RISE Program  in Colorado  as of                                                               
October 2018, noting that this  still raised serious concerns for                                                               
5:59:11 PM                                                                                                                    
MR.  BARR offered  a point  of clarification,  pointing out  that                                                               
this program  was in  the Arapahoe County  Sheriff's office.   In                                                               
2013, Wellpath Recovery Solutions  entered into an agreement with                                                               
the Office  of Behavioral Health  to provide services  similar to                                                               
those provided at  the state hospital.  He pointed  out, as there                                                               
was litigation  surrounding people in jails,  the treatment could                                                               
then be brought to the individuals  rather than wait for a bed at                                                               
the  hospital.   Independent of  that, the  health care  services                                                               
were  being provided  by a  local health  care component  and the                                                               
incidences  were related  to that  program  and not  to the  Rise                                                               
REPRESENTATIVE   SPOHNHOLZ   asked   if  another   provider   was                                                               
responsible for those deaths.                                                                                                   
MR.  BARR  said  that  the   wrongful  death  lawsuits  were  not                                                               
associated by  the care delivered by  Wellpath Recovery Solutions                                                               
in association with the Rise Program in Colorado.                                                                               
6:00:42 PM                                                                                                                    
MR. BARR moved on  to slide 12, "Phase 1 and Phase  2 Goals."  He                                                               
paraphrased from Phase 1, which read:                                                                                           
     Assess current operations ?  Regain compliance with all                                                                    
     regulatory  authorities ?  Provide training  to improve                                                                    
     patient  care  and  staff safety  ?  Train  on  trauma-                                                                    
     informed  care and  de-escalation techniques  ? Recruit                                                                    
     key  leadership  team  ?  Improve  communication  among                                                                    
     leadership  and  staff  ?  Improve  communication  with                                                                    
     community stakeholders                                                                                                     
MR.  BARR  directed  attention  to   Phase  2,  the  more  active                                                               
transition, and paraphrased slide 12, which read:                                                                               
     Maintain compliance with  regulatory authorities ? Hire                                                                    
     staff to fill vacancies  ? Prepare to increase capacity                                                                    
     to 80 beds  ? Implement a culture of  safety ? Increase                                                                    
     active, evidenced-based treatment  programming ? Reduce                                                                    
     seclusion and  restraint ?  Engage families  ? Improve,                                                                    
     build,  and maintain  strong community  relationships ?                                                                    
     Improve  integration of  API  within  the continuum  of                                                                    
6:01:42 PM                                                                                                                    
CO-CHAIR ZULKOSKY  directed attention to  the dates for  Phase 1,                                                               
identified as  February 8 - June  30, 2019, in the  contract with                                                               
Wellpath  and the  State of  Alaska, which  stated:   "during the                                                               
start-up phase  the contractor shall take  all actions reasonably                                                               
necessary for API to be in  full operation and capable of serving                                                               
patients  by  June  30,  2019."    She  said  that  Phase  2  was                                                               
identified to begin  July 1, 2019 - June 30,  2024, and she asked                                                               
for Mr.  Barr to share  his understanding of the  contract beyond                                                               
April 15.  She  questioned how April 15 could be  a point in time                                                               
for a decision  on this contract moving forward  for an effective                                                               
date that was written into the contract beginning July 1, 2019.                                                                 
6:02:35 PM                                                                                                                    
MR.  BARR apologized  for any  confusion  from the  dates on  the                                                               
slide,  as  they were  not  meant  to represent  any  contractual                                                               
terms.   He  explained  that the  dates  reflected the  mechanics                                                               
associated with  the hiring  process that  dictated an  amount of                                                               
time for onboarding  staff.  He noted that there  was an eight to                                                               
ten-week process for each person hired  to be ready to go on July                                                               
6:04:36 PM                                                                                                                    
CO-CHAIR ZULKOSKY asked  if it was Mr.  Barr's understanding that                                                               
the contract for Phase 2 would  likely move forward if they began                                                               
active transition on April 15.                                                                                                  
6:04:45 PM                                                                                                                    
MR.  BARR  replied that  it  was  his  understanding so  long  as                                                               
Wellpath  continued   to  provide  the  services   and  meet  the                                                               
expectations  of  Department of  Health  and  Social Services  in                                                               
terms of preparation.  He said  if Wellpath failed to fulfill its                                                               
obligations, there was a 30-day termination clause.                                                                             
6:05:10 PM                                                                                                                    
CO-CHAIR  SPOHNHOLZ  asked  when  Wellpath had  been  invited  to                                                               
submit its contract.                                                                                                            
MR. BARR replied that he was not  aware of the exact date, but he                                                               
would get it to her.                                                                                                            
CO-CHAIR  SPOHNHOLZ directed  attention to  the provision  in the                                                               
contract which stated that it  was subject to appropriation.  She                                                               
reported that Department  of Health and Social  Services had only                                                               
requested  $33  million,   as  the  state  was   "facing  a  very                                                               
challenging budget structure"  and it was necessary  to make very                                                               
tough decisions for which basic  services could be provided.  She                                                               
offered  her understanding  that the  proposed Wellpath  contract                                                               
obligated the State  of Alaska to $44 million if  API operated at                                                               
full capacity.   She asked what the decision  point from Wellpath                                                               
was for pulling out of a  contract if there was not the necessary                                                               
appropriation to fully meet the contract obligation.                                                                            
6:06:35 PM                                                                                                                    
MR. BARR explained that, as  Wellpath contracted exclusively with                                                               
government entities,  these appropriation  clauses were  in most,                                                               
if not all,  of their contracts.   In the event there  was not an                                                               
appropriation, Wellpath  would review the situation  and see what                                                               
other options existed.  He stated  that he could not offer a firm                                                               
answer  without  knowing  more   specifics.    He  declared  that                                                               
Wellpath was  committed to doing  the right thing, that  they had                                                               
had success  in other circumstances,  and they believed  that the                                                               
plan presented what was necessary for success.                                                                                  
6:07:18 PM                                                                                                                    
MR. BARR announced slide 13,  "Recruitment," noting that Wellpath                                                               
had about  as many employees  as the  State of Alaska;   however,                                                               
the key difference  was that Wellpath only  focused on recruiting                                                               
and employing health  care professionals.  He  cited the shortage                                                               
of  psychiatrists in  Alaska and  nationally  and explained  that                                                               
psychiatrists  were now  a part  of their  recruitment team.   He                                                               
stated that the vast majority of  the "line staff" would be hired                                                               
from  the local  Alaska work  force as  it was  not practical  to                                                               
recruit outside a given state.   He pointed out that Wellpath had                                                               
often  partnered  with  universities  to  fund  placements.    He                                                               
declared that the first priority was retention.                                                                                 
6:11:03 PM                                                                                                                    
The committee took an at-ease from 6:11 p.m. to 6:12 p.m.                                                                       
6:12:33 PM                                                                                                                    
DR. HUCKSHORN  turned attention  to slide  14, "Accomplishments,"                                                               
and paraphrased from the slide, which read:                                                                                     
     Deployed  team  to  API within  72  hours  of  contract                                                                    
     execution  ? Assisted  with responses  to the  Plans of                                                                    
     Correction  to the  Centers for  Medicare and  Medicaid                                                                    
     Services (CMS),  The Joint Commission (TJC),  and other                                                                    
     bodies ? Conducted MANDT  presentation to introduce new                                                                    
     de-escalation  training for  direct  care  staff ?  Met                                                                    
     with   API   Governing    Board   members   and   other                                                                    
     stakeholders, including  ASHNA, ABHA,  AMHB/ABADA, NAMI                                                                    
     Anchorage,  et  al  ?  Partnering  with  South  Central                                                                    
     Foundation  to provide  cultural training  for staff  ?                                                                    
     Began staff  training in trauma-informed  care, patient                                                                    
     rights,  and restraint  and seclusion  ? Held  multiple                                                                    
     all-staff  town hall  meetings to  ensure communication                                                                    
     and  transparency to  API  staff  ? Implemented  weekly                                                                    
     meetings  with  API  leadership  ?  Implemented  safety                                                                    
     huddles ? Began recruiting  for consultant positions to                                                                    
     support key management positions                                                                                           
6:17:28 PM                                                                                                                    
DR.  HUCKSHORN  moved  on  to slide  15,  "Staff  Feedback,"  and                                                               
reported that  the staff at  API were a  "committed, professional                                                               
group of  staff that really  seem to  care about what  happens to                                                               
that facility."   She praised the staff's  dedication and loyalty                                                               
to API.                                                                                                                         
6:18:23 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ thanked Dr. Huckshorn  for recognizing the API                                                               
staff.   She stated that  the staff needed  leadership, training,                                                               
and support.   She cited  her concerns with the  privatization of                                                               
API regarding  staff compensation and  benefits, and asked  for a                                                               
statement on the record as to how they intended to handle that.                                                                 
6:20:11 PM                                                                                                                    
MR. BARR replied that  no one would go backward in  pay.  He said                                                               
that  there were  a number  of areas  where staff  were currently                                                               
underpaid, which  he opined  was part  of the  problem.   He said                                                               
that Wellpath would  look at a compensation  analysis and address                                                               
the unfairness  of new hires being  paid more than veterans.   He                                                               
stated  that there  would  be an  equitable  treatment of  staff.                                                               
Regarding  benefits, Wellpath  offered a  retirement plan  with a                                                               
401(k) and a  company match, as well as health,  life, and dental                                                               
plans.   He  pointed out  that there  was no  waiting period  for                                                               
benefits.  He declared that staff tenure would be recognized.                                                                   
6:21:45 PM                                                                                                                    
CO-CHAIR SPOHNHOLZ asked  about the cost for the  State of Alaska                                                               
to buy out  peoples' retirement in order to  make this transition                                                               
6:22:21 PM                                                                                                                    
CO-CHAIR ZULKOSKY recognized  the people who had  been invited to                                                               
testify and asked that they provide written testimony.                                                                          
6:23:33 PM                                                                                                                    
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 6:23 p.m.