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