SENATE BILL NO. 36 "An Act extending the termination date of the Board of Nursing; and providing for an effective date." 1:31:18 PM JANE CONWAY, STAFF, SENATOR CATHY GIESSEL, explained that the sponsor could not be present, as she was attending Floor Session. She explained that the bill extended the Board of Nursing for six years. Otherwise, the board was set to expire on June 30, 2019. She provided additional details of the bill. The board was established for the purpose of regulating the practice of nursing; and covered advance-practice registered nurses, nurse anesthetists, registered nurses, licensed practical nurses, and certified nurse aides (CNA). Ms. Conway continued that the board had almost 20,000 licensees, which she thought was near to one-third the workload of professional licensees. Co-Chair Wilson clarified she was addressing SB 36 rather than SB 37. Ms. Conway discussed education requirements for the licensees, which spanned from high school diplomas to doctoral degrees. The board of seven individuals served four-year terms and were capped at two consecutive terms. The board's mission was to actively promote and protect the health of citizens of Alaska through safe and effective practice of nursing as defined by law. The 2018 audit cited four recommendations. She indicated the legislative auditor was present to provide the audit findings. The board received its revenue from licensing and renewal fees, and deficits were shown on page 11 of the audit. The board was self-sustaining and required no general funds. The audit of the board concluded that the board continued to meet its mission and recommended its six-year sunset. 1:34:33 PM Co-Chair Wilson asked about page 11 of the audit. It appeared there was a deficit for the board for the first time. She wondered why. Ms. Conway believed there had been a large influx of licensees. There would be a fee analysis in May. She thought the division director could provide more detail. Representative Josephson had been told the board did not have an executive administrator at present. He wondered if the position would be filled in the near future. Ms. Conway thought the board was actively pursuing the recruitment of the position. 1:36:37 PM SARA CHAMBERS, DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, responded that the department was actively recruiting for the executive administrator position which would close the following day. Representative Josephson thought the board consisted almost entirely of new members. He referenced telemedicine regulations and asked if Ms. Chambers could explain the turnover. Ms. Chambers was unsure of the reason for the turnover. She assured the committee that every effort was being made to bring new members up to speed and avoid a gap in service. Co-Chair Wilson directed Ms. Chambers to respond to her query about the deficit. Ms. Chambers informed that she had submitted an updated fiscal report to the committee on the previous Friday, while the audit was a year old. She detailed that as of March 30, 2019, the board had a $1 million surplus. The funds were adequate to maintain the licensing program activities for a biennial licensing period. She noted that page 11 of the audit was based on a time just before a renewal period. She stated that it was not unusual to see a flux of funds based on the schedule of renewals. Co-Chair Wilson asked for the document date. Ms. Chambers answered that the latest document that was provided was for the end of the third quarter and showed a $1,441,000 surplus as of March 30, 2019. 1:39:17 PM AT EASE 1:40:06 PM RECONVENVED KRIS CURTIS, LEGISLATIVE AUDITOR, ALASKA DIVISION OF LEGISLATIVE AUDIT, reported that the audit concluded that the board was serving the public interest. The audit also concluded that the board was not serving the public's interest by not establishing telehealth regulations; by not adequately monitoring CNA training programs; and by not notifying the appropriate entities when a licensee's prescriptive authority had been suspended, revoked, or surrendered. The audit also found that there needed to be improvements in the investigative process of the Division of Corporations, Business and Professional Licensing. The audit recommended extension of the board for six years. Ms. Curtis directed attention to page 7 of the audit report, which showed licensing activity and a 46 percent increase in activity since the previous 2010 sunset audit. The amount of applications reflected a growing occupation. She noted that the schedule of expenditures was on page 11 of the audit. She made note of the $337,000 deficit as of March 2018. She continued that the fees were adjusted. Ms. Curtis referenced page 14 of the audit which contained the recommendations from the Division of Legislative Audit. She read the four recommendations: Recommendation No. 1: The board should adopt regulations to address the distance delivery of nursing services through technology. The board has permitted the distance delivery of nursing services via technology (telehealth) without formal statutory or regulatory guidance. In FY 15, a licensee approached the board and asked for guidance on providing telehealth services which prompted the board to issue an advisory opinion. The board's advisory opinion defined telehealth and provided limited guidance on the scope of practice. The guidance was inadequate to promote, preserve, and protect the public's health, safety, and welfare. Although the board discussed the need for regulations to guide the distance delivery of nursing services, the board could not agree on regulatory language. Per AS 08.68.100(a)(1), the board shall adopt regulations pertaining to the scope of practice of nursing in Alaska. Providing insufficient guidance to licensees increases the risk that nurses may not maintain acceptable standards of practice or may not adequately protect patients' confidentiality. We recommend the board adopt regulations to address the distance delivery of nursing services through technology. Additionally, the board should ensure statutes appropriately allow for the establishment of telehealth regulations. Recommendation No. 2: The board should take steps to ensure the appropriate entities are notified when a licensee's prescriptive authority is suspended, revoked, or surrendered. The audit identified eight APRNs that had their prescriptive authority suspended, revoked, or surrendered between July 1, 2014, and January 31, 2018. In all cases, the board did not notify the Board of Pharmacy or the Drug Enforcement Administration (DEA) about the licensing action. The entities were not notified because there were no statutes or regulations in place that require notification. The board is established under AS 08.68 for the purpose of controlling and regulating the practice of nursing, including: APRNs, nurse anesthetists, registered nurses, LPNs, and CNAs. The board's mission statement is: "to actively promote and protect the health of the citizens of Alaska through the safe and effective practice of nursing as defined by law." Per AS 17.30.200, the Board of Pharmacy is responsible for administering the controlled substance prescription database. The database is reviewed by pharmacists prior to dispensing controlled substances, with certain exceptions. Failure to notify the Board of Pharmacy when prescriptive authority has been revoked, suspended, or surrendered increases the risk that controlled substances may be abused or diverted. Per federal law, the DEA may rescind or revoke the federal authority to prescribe controlled substances if an existing DEA registrant loses his or her state privileges. Failure to notify the DEA that an APRN's prescriptive authority has been suspended, revoked, or surrendered may result in improper or unauthorized prescriptions. We recommend the board take steps to ensure the appropriate entities are notified when a licensee's prescriptive authority is suspended, revoked, or surrendered. 1:43:29 PM Ms. Curtis continued discussing the audit: Recommendation No. 3: The DCBPL chief investigator should ensure nurse investigations are adequately documented and performed timely. The audit identified 13 investigations with periods of unjustified inactivity and two investigations which were inadequately documented. Specifically: Thirteen cases in a random sample of 2810 had periods of unjustified inactivity ranging from 61 days to 3.6 years. Furthermore, 10 of the 13 cases had multiple periods of inactivity. The periods of unjustified inactivity were mainly due to changes in investigative staff assigned to the case and competing priorities. The long-term care ombudsman identified two licensees for investigation that were potentially practicing outside a LPN's scope of practice. Auditors could not evaluate the investigations due to a lack of documentation in the DCBPL case fi les. One of the licensees continued to practice during the four years that the investigation was open, potentially posing a risk to public safety. The DCBPL investigator fi les note that the two cases were put in storage from October 2012 until April 2014 due to an office remodel and did not progress during that time. Per AS 08.01.050(a)(19), DCBPL is responsible for investigating and monitoring occupational licensing activity. Investigations and complaints that sit idle for extended periods may pose a risk to public safety. We recommend the DCBPL chief investigator ensure nurse investigations are adequately documented and performed timely. Recommendation No. 4: The board chair should take steps to ensure the required CNA on-site training program reviews and self-evaluations are conducted prior to reapproving the programs. The audit found the required self-evaluations were not received and on.notdefsite reviews were not conducted prior to board re.notdefapproval of CNA training programs. During the audit, the process to approve five of 22 CNA training programs was reviewed. Auditors found on site reviews were not conducted for four of the five programs as required prior to re-approval. Additionally, self-evaluations were not obtained and reviewed. The board's failure to adequately monitor programs may lead to undetected deficiencies, which could result in inadequately trained CNAs. According to board staff, on-site reviews and monitoring of self-evaluation forms were not completed timely because the contractor hired to complete the reviews was terminated in FY 14, and procurement to hire another contractor was not successful. DCBPL received approval for a nurse consultant position, which was filled in October 2015; however, the nurse consultant did not begin performing reviews until spring 2016. Programs were approved by the board without on-site visits or self-evaluations due to a lack of resources to complete the reviews and a need for the programs to continue to be available to train CNAs. Regulation 12 AAC 44.857(a) and (c) requires CNA training programs be board-approved every two years with an on-site review. Self-evaluations are to be completed during a year in which an on-site review is not scheduled. We recommend the board chair take steps to ensure the required CNA training program on-site reviews and self-evaluations are conducted prior to reapproving the programs. 1:46:22 PM Ms. Curtis pointed out that the department response was found on page 27 of the audit. The department did not comment on recommendations 1 and 4, which were directed to the board. The department agreed with recommendations 2 and 3. Administrative procedures had been implemented to notify the Board of Pharmacy and the Drug Enforcement Agency when licensing action was taken. Additionally, procedures had been improved to help improve the timeliness of the investigative process. She added that the board's response was found of page 29 of the audit. The board did agree with all four recommendations and planned to take corrective action. Representative Josephson asked about the telemedicine recommendation. He was told that the board had submitted a regulation packet the previous fall and wondered if the auditor had seen it. Ms. Curtis informed that the audit was dated April 2018. The board's response to the audit indicated that it planned to take corrective action in November 2018. Ms. Chambers reviewed the fiscal note from the Department of Commerce, Community and Economic Development (DCCED) that reflected the cost of extending the board. The bill did not change the licensing program. If the bill was unsuccessful and the board sunset, there would be no change. If there was an extension of the board; DCCED had proposed $28,400 to cover travel for the board to meet as required, to advertise public meetings, and for various training and conference fees. Co-Chair Wilson highlighted that page 3 showed the board costs and licensing fees. Representative Knopp asked Ms. Chambers about recommendation 4 regarding CNAs. He referred to a previous conversation. Ms. Chambers reported that the board had addressed all four of the audit recommendations and regulations were moving forward. The CNA program was moving forward with evaluations as prescribed by law. She discussed the importance of licensing in a timely manner. She reported that the division was fully staffed. The department was always looking to do more streamlining of processes, particularly with regard to military spouses and healthcare facilities that needed to get people on staff quickly. 1:50:23 PM Representative Knopp referred to the military spouse issue. He asked how long it took for CNA licensees to receive a license once they have applied. Ms. Chambers stated that once a licensee submitted the legally required elements, the department usually processed the application in two weeks. 1:51:15 PM Co-Chair Wilson OPENED Public Testimony. CHRIS LOGAN, ALASKA ADVANCE PRACTICE REGISTERED NURSE ASSOCIATION ALLIANCE, ANCHORAGE (via teleconference), spoke in support of SB 36. She relayed that the alliance supported the bill. She discussed the importance of the Board of Nursing. She urged the committee to pass the bill. 1:52:28 PM LYNN HARTZ, SELF, ANCHORAGE (via teleconference), spoke in favor of advancing SB 36. She thanked the committee. She thought the Board of Nursing was an essential government tool in promoting the health and welfare of the Alaska public. She expressed that through licensure, oversight of education and discipline, the board and its staff exert vital and unique functions on the states behalf and should be allowed to continue their important work. 1:53:20 PM KAREN MORTON, ALASKA NURSES ASSOCIATION, SOLDOTNA (via teleconference), strongly supported SB 36. She read from a prepared statement. She discussed the work of the Alaska Nurses Association. She thought the board worked in a transparent fashion and ensured that regulations utilizes best practices. 1:54:50 PM Co-Chair Wilson CLOSED Public Testimony. Co-Chair Wilson indicated amendments were due on Wednesday, May 1, 2019 by 5:00 P.M. SB 36 was HEARD and HELD in committee for further consideration.