SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE February 23, 1994 1:40 p.m. MEMBERS PRESENT Senator Steve Rieger, Chairman Senator Bert Sharp, Vice-Chairman Senator Loren Leman Senator Mike Miller Senator Jim Duncan Senator Judy Salo MEMBERS ABSENT Senator Johnny Ellis COMMITTEE CALENDAR SENATE BILL NO. 249 "An Act relating to assisted living homes; repealing references to residential facilities for dependent adults; and providing for an effective date." SENATE BILL NO. 319 "An Act relating to the possession of controlled substances within 500 feet of recreation and youth centers; and permitting municipalities to install `drug-free recreation and youth center zone' signs." CS FOR HOUSE BILL NO. 195(FIN) "An Act authorizing youth courts to provide for peer adjudication of minors who have allegedly committed violations of state or municipal laws, and renaming the community legal assistance grant fund and amending the purposes for which grants may be made from that fund in order to provide financial assistance for organization and initial operation of youth courts." PREVIOUS SENATE COMMITTEE ACTION SB 249 - See Health, Education & Social Services minutes dated 2/2/94, 2/4/94, and 2/16/94. SB 319 - No previous action to record. HB 195 - No previous action to record. WITNESS REGISTER Connie Sipe Executive Director, Division of Senior Services Department of Administration P.O. Box 110209 Juneau, Alaska 99811-0209 POSITION STATEMENT: Reviewed SB 249. Ken Erickson Staff to Senator Pearce State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Reviewed SB 319. Paula Terrel Staff to Representative Sitton State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Reviewed HB 195. Anne Walker, Executive Director Alaska Native Health Board 1345 Rudakof Circle Anchorage, Alaska POSITION STATEMENT: Reviewed ANHB State Legislative Priorities for or Fiscal Year 1995. Katherine Johnson, Treasurer Alaska Native Health Board, Representative for South Central Foundation 1345 Rudakof Circle Anchorage, Alaska POSITION STATEMENT: Reviewed ANHB State Legislative Priorities for or Fiscal Year 1995. Paul Manumik, Member Alaska Native Health Board 1345 Rudakof Circle Anchorage, Alaska POSITION STATEMENT: Present for information. Joseph Dexter, Executive Committee Member Alaska Native Health Board 1345 Rudakof Circle Anchorage, Alaska POSITION STATEMENT: Present for information. ACTION NARRATIVE TAPE 94-12, SIDE A Number 006 CHAIRMAN RIEGER called the Senate Health, Education and Social Services (HESS) Committee to order at 1:40 p.m. He introduced SB 249 (REGULATION OF ASSISTED LIVING HOMES) as the first order of business before the committee. SENATOR MILLER moved to adopt the CS of SB 249, Lauterbauch 8- GS2002\E. Hearing no objections, the CS was adopted. CONNIE SIPE, Director of Senior Services, referred to page 25, line 29 of the CS when noting the insertion of the definition of a "terminally ill resident." She noted that this definition is commonly accepted and used by Medicaid. CHAIRMAN RIEGER noted that this language was before the committee because the CS had been adopted. There was no objection to the language of the inserted definition. CONNIE SIPE pointed out the new definition of "resident" on page 25, line 23 of the CS. There was no objection to this language change. She noted that on page 24, line 14 of the CS the words "to the resident's self, to the staff of a home, or to others;" had been added to the definition of "imminent danger." There were no objections to that language change. Ms. Sipe highlighted the new sections that Lauterbauch had added. Page 26, Section 2 and Section 3 added assisted living homes to the list of licensed centers where it is a crime to possess weapons on such properties. These sections also discuss the results of misconduct of weapons on such properties. She explained that this addition was due to the assisted living homes being licensed by Department of Family and Youth Services. Ms. Sipe stated that subsection (b) on page 3 intends to avoid assisted living homes from becoming primarily nursing homes. She mentioned that on line 11 of subsection (b), the word "only" seems too restrictive. She suggested deleting the word "only." She explained that the regulating agency should have more flexibility to give waivers for rural conditions or to allow other health care. She noted that the word "only" on line 12, page 3 addresses those individuals trying to operate as a mini-nursing home or rehabilitation home with no intent of long term care. Number 191 CHAIRMAN RIEGER moved to adopt Amendment 26. AMENDMENT 26  Page 3, line 11: Delete "only" Hearing no objections, Amendment 26 was adopted. Chairman Rieger pointed out that page 6, line 22 incorporated a previous amendment, but the change did not include the words " but not limited to." He assumed that was not included because the wording was implicit. CHAIRMAN RIEGER expressed concern with the Residents' Rights language. He was concerned that the use of the word "rights" would require the assisted living home to expend money beyond what is in the residential services contract. He cited examples of this possible problem: page 11, paragraph (3); page 12, paragraph (6) and (10). He explained that those examples seem to create an obligation of the home that are not in the contract. He expressed the need to have clarification on this issue. CONNIE SIPE stated that this bill attempts to address past abuses. She suggested adding language which clarifies that the home does not have an obligation to provide these "rights", but that the resident has access to these "rights." She also reiterated Chairman Rieger's previous suggestion to change them from "rights" to "standards" that must be present in the contract. She also suggested adding language that would not require the facility to expend funds or guarantee that a resident has all the benefits and services; however, that resident would not be restricted from receiving them. SENATOR SALO noted that the resident must be informed of their rights. CONNIE SIPE explained that this Residents' Rights section was meant to be a balance. Ms. Sipe likened this section to the Tenant Landlord law. She recommended adding a subsection (c) or regrouping of the paragraphs in order to alleviate Chairman Rieger's concerns. Number 283 SENATOR SALO stated that a generic subsection would be difficult to add. She pointed out that there are qualifiers, such as the word "reasonable" on line 14 of page 12 which are already present on some of the rights. She explained that her main concern was with upholding the residents' rights. CHAIRMAN RIEGER explained that he did not want to create a right without knowing what was being created. He pointed out that the fiscal note includes state facilities which often times means that the court will have an open checkbook. He suggested taking the rights separately and where appropriate adding Ms. Sipe's clause. SENATOR SALO agreed that taking the rights separately would be more appropriate than a general clause. CHAIRMAN RIEGER asked if after the word "resident;" on page 11, paragraph (3) the language stating "this subsection does not create an obligation for the assisted living home to provide these items" would be satisfactory to the intent. CONNIE SIPE said it would work, but pointed out that if an individual does not own the items then it is not theirs. She agreed that in order not to create new rights Chairman Rieger's suggested language would work. CHAIRMAN RIEGER cited paragraphs (3), (4), (12), and (14) as rights that needed qualifiers stating that, "these do not create an obligation for the home to expend resources to provide the items unless specified in the contract." He felt paragraphs (6) and (10) were different. SENATOR LEMAN recommended that paragraph (7) should have a qualifier in order to be consistent. CHAIRMAN RIEGER stated that if paragraph (7) said "possessed" money it would be the same case as paragraph (3). SENATOR SALO suggested eliminating the words "possess and" in paragraph (3) which would parallel paragraph (7). CHAIRMAN RIEGER agreed that deletion would work for paragraph (3). CONNIE SIPE noted that "the possession of" on line 29 should also be deleted. CONNIE SIPE asked for clarification of Chairman Rieger's concerns with paragraph (4) of the Residents' Rights section. CHAIRMAN RIEGER suggested adding following clause: "this subsection does not create an obligation for the assisted living home to provide these items or to expend resources to provide these items" at the end of paragraphs (3), (4), (12), and (14). SENATOR SALO referred to page 12, line 4 when recommending changing "visits with" to "visits from." CHAIRMAN RIEGER agreed with Senator Salo's suggestion and believed that the generic clause would not be necessary. Chairman Rieger reconsidered and believed that the possibility that the home would become obligated was still present in Senator Salo's language change. Number 401 CHAIRMAN RIEGER stated his proposed disclaimer, "this subsection does not create an obligation for the assisted living home to expend money to provide these items, unless provided for in the residential services contract." This language would be inserted at the end of paragraphs (3), (4), (7), (12), and (14). Chairman Rieger moved to adopt this language, Amendment 27. AMENDMENT 27  Page 12, at the end of paragraphs (3), (4), (7), (12), and (14): Insert " this subsection does not create an obligation for the assisted living home to expend money to provide these items, unless provided for in the residential services contract " SENATOR SALO objected. After a hand vote, Amendment 27 was adopted. CHAIRMAN RIEGER recommended that paragraph (6) should have a qualifier. After the word "from" the following clause ", at the resident's own expense unless provided for in the residential services contract," should be inserted. Chairman Rieger moved to adopt this language insertion, Amendment 28. AMENDMENT 28  Page 12, line 8, after "from": Insert " , at the resident's own expense unless provided for in the residential services contract,"  SENATOR SALO clarified the clause with an example. She stated that a home could have a van to carry residents to activities, but the home would not be required to provide a van. CHAIRMAN RIEGER agreed with that example. Hearing no objections, Amendment 28 was adopted. CONNIE SIPE said that paragraph (10) could be put into programmatic standards. She emphasized that the crucial part of paragraph (10) is the resident's right to go outdoors. Having a "reasonable opportunity" must remain. She explained that without this right, arguably homes could lock residents inside. CHAIRMAN RIEGER asked why there is a comma after "week" on line 15, page 12; does a "reasonable opportunity" only apply to exercise but not outdoors. CONNIE SIPE suggested deleting "to exercise at least several times a week, and" in paragraph (10). SENATOR SALO asked Ms. Sipe how that would read. SENATOR SALO suggested deleting "at least several times a week," from paragraph (10). CHAIRMAN RIEGER moved to adopt Amendment 29. AMENDMENT 29  Page 12, line 14: Delete "at least several times a week," Hearing no objections, Amendment 29 was adopted. SENATOR SHARP suggested adding, "subject to the consent of the resident," after "home" on page 13, line 25. He was concerned that "shall" mandates that the resident must allow the advocates in the home. CONNIE SIPE explained that on page 23, the definition of an advocate requires that in order to be an advocate one must be designated by the federal or state statute, like the long term care Ombudsman and the Alaska Advocacy Services program. Number 507 SENATOR SHARP asked if Veteran's Services Officers would meet the definition of an advocate. CONNIE SIPE said yes and asserted that any individual would have to be official. SENATOR SHARP explained that the "shall" aspect would infringe on the residents privacy. He did not want anyone to be routed to individual resident's rooms; it should be subject to the resident's consent. CONNIE SIPE asked if there could still be group meetings which the residents could choose to attend or not. SENATOR SHARP said yes. CHAIRMAN RIEGER moved to adopt Amendment 30. AMENDMENT 30  Page 13, line 24, after "home": Insert " , subject to the consent of the resident, " Hearing no objections, Amendment 30 was adopted. CONNIE SIPE referred to page 14, line 26 when noting that at present, that sentence implies that there may be other times when the home could physically restrain residents. She suggested changing the sentence to read: "An assisted living home may not physically restrain a resident unless the resident's own actions presents an imminent danger to the resident or others, in which instance," and leave the remainder of the sentence in tact. This change would basically clarify the standard of imminent danger. SENATOR LEMAN asked if subsection (b) on page 14 imposed a burden on other services that may not be intended. He questioned the necessity to report to the listed personnel during short limited instances of restraint. CONNIE SIPE pointed out that the assisted living home has to have a written policy that would have to be approved by the licensing agency. Each instance will be different depending on the size and location of the home. She said that the licensing agency would determine what was appropriate in the different facilities. SENATOR LEMAN asked if current practice is to always report physical restraint to emergency personnel even if it is a one or two minute incident. CONNIE SIPE pointed out that the last sentence in subsection (b) addresses that issue. If the restraint is short term then the physical restraint could stop as well as the reporting of it, but there must be a procedure for ongoing restraint. She explained that these homes are not correctional facilities and if they physically restrain residents, professional help should be present. SENATOR SALO agreed with Senator Leman's interpretation of the language in subsection (b). She believed that there would be instances that would waste the time of the listed personnel due to the lack of physical restraint standards regarding reporting. CONNIE SIPE stated that someone more familiar with restraint protocols would be able to answer Senator Leman and Senator Salo's concerns with subsection (b). TAPE 94-12, SIDE B Number 591 CHAIRMAN RIEGER recommended that this issue be discussed further at another hearing. He also noted that paragraphs (17) and (18) on page 12 should have qualifiers. He suggested holding SB 249 until Monday. Chairman Rieger stated that Amendment 28 should precede paragraphs (17), (18), and (6) on page 12. CONNIE SIPE suggested deleting all of subsection (b) on page 14 except the first sentence, in order to address Senator Leman and Senator Salo's concerns regarding physical restraint. The reporting aspect would be dealt with through the individual home working out their own procedure that would have to meet appropriate protocol standards on restraint. SENATOR SALO explained that the last sentence of subsection (b) should be retained in order to address the termination of the physical restraint when it is no longer necessary. CHAIRMAN RIEGER held SB 249 until Monday. He requested that Mr. Williams be present at the next meeting to discuss the fiscal note. Number 561 CHAIRMAN RIEGER introduced SB 319 (DRUG FREE RECREATION AND YOUTH CENTERS) as the next order of business before the committee. KEN ERICKSON, Staff to Senator Pearce, read Senator Pearce's sponsor statement. SENATOR LEMAN asked if the reference to associated buildings applies to municipal constructions. KEN ERICKSON pointed out that Section 5 provides the definition of a "recreation or youth center." Mr. Erickson said yes those would be included. SENATOR SALO asked if a controlled substance included alcohol and tobacco. KEN ERICKSON did not believe that alcohol or tobacco were included in the laundry list in the statutes. SENATOR SALO explained that the drug free zones around schools clearly did include alcohol and tobacco. She asked if they also used the language "controlled substance" and if they were changing the same part of the statute. KEN ERICKSON stated that youth centers are added to those currently listed in statutes. SENATOR SALO noted that lay people would interpret "controlled substances" to include alcohol and tobacco. She explained that preventing the use of alcohol and tobacco in school during school hours was not a problem; but when the facilities are used by adults, problems with this drug free zone occur. She expressed concern that if this language does include alcohol and tobacco there would be numerous problems since this legislation speaks to many adult used facilities. CHAIRMAN RIEGER noted that SB 319 refers to schedules which classify controlled substances. SENATOR SALO emphasized the need to definitely know if "controlled substance" includes alcohol and tobacco because this could be a felony. KEN ERICKSON reviewed the statutes and did not see alcohol and tobacco listed. SENATOR LEMAN moved that SB 319 be passed out of committee with individual recommendations. Hearing no objection, it was so ordered. Number 485 CHAIRMAN RIEGER introduced HB 195 (AUTHORIZING YOUTH COURTS) as the he next order of business before the committee. PAULA TERREL, Staff to Representative Sitton, gave an overview of the sponsor statement. She pointed out that this youth court program is modeled after the Anchorage program which has been successful. She stated that Representative Sitton wanted to use this legislation in order to help the kids without throwing them in jail. HB 195 establishes the authority to establish the Youth Court as a diversionary program and sets up a grant program. She noted that in the Anchorage program, participation of the community was shown to be essential to the programs success. HB 195 allows flexibility to rural and urban communities to establish programs based upon their specific needs. She noted that HB 195 allows the Youth Court to subpoena witnesses. She expressed the support of HB 195 from the Anchorage youths who have participated in the program. SENATOR SHARP asked if the subpoenas would be an added cost that is not done through the Division of Family and Youth Services (DFYS). PAULA TERREL said there would not be any extra cost for the administration of the program. This is done through FYS not the court system. CHAIRMAN RIEGER asked what page 3, line 8 means; "may secure jurisdiction over a juvenile." PAULA TERREL explained that Juvenile Intake, of the Department of Health and Social Services (DHSS), can refer a minor who has committed a misdemeanor to the jurisdiction of the Youth Court. The parents of the minor, the minor, and the Juvenile Intake officer must all approve of the minor being sent to Youth Court. She clarified that Alaska Statute 18 refers to DHSS. CHAIRMAN RIEGER asked if the authority is delegated by the statute or from the court due to this statute enabling the court to have the authority. PAULA TERREL stated that originally this was purview of the court, but now it has shifted to Juvenile Intake of DHSS. She noted the need for some clean up language in the statutes. Basically the court system is not involved at all. Number 412 SENATOR LEMAN asked what case can be referred to the Youth Court. PAULA TERREL explained that DHSS would not refer nor would the Youth Court accept severe felony cases such as murder. HB 195 would not conflict with the juvenile waiver bill. CHAIRMAN RIEGER stated that Senator Leman's concern could be addressed by inserting language on page 2, line 23 that would specify that the case be a misdemeanor and the class of felony the Youth Court would accept. PAULA TERREL expressed concern that such an amendment should not hamper the Anchorage Youth Court and the tasks it is already doing. CHAIRMAN RIEGER asked if the Anchorage model would be included if HB 195 passes. PAULA TERREL said yes. SENATOR LEMAN said that knowing there is some protection sets his mind at ease. He believed that having his concern on the record is sufficient at this point. SENATOR SALO moved to pass CSHB 195 (FIN) out of committee with individual recommendations. Hearing no objections, it was so ordered. CHAIRMAN RIEGER invited the Alaska Native Health Board (ANHB) to come forward to give their presentation. ANNE WALKER, Executive Director of ANHB; KATHY JOHNSON, Treasurer and Representative for South Central Foundation of the ANHB; JOSEPH DEXTER, Chairman of the Nordan Sound Health Corporation Board of Directors and Executive Committee member of ANHB; and Paul Manumik, ANHB member introduced themselves to the committee. Number 355 ANNE WALKER explained that the ANHB represents 93,000 Alaska natives on health care issues. ANHB is the standing health committee of the Alaska Federation of Natives. She stated that ANHB supports SB 284 and SB 259. She explained that mandatory health education in the schools is needed; she urged a senate companion to HB 320. Ms. Walker expressed support for an anti-tobacco program. She pointed out that the committee could help by supporting the Governor's proposed increase in tobacco tax. She stated that ANHB supports a $1, as opposed to the Governor's 42 cents, per pack cigarette tax. The increased tax would prevent easy access to tobacco for children. Ms. Walker stated ANHB support of SB 235. Number 311 KATHY JOHNSON referred to the ANHB briefing paper on "Home and Community Based Services" when noting that in 1993 federal waivers allowed Medicaid funds to be used to provide home and community based services in Alaska; however, Medicaid limitations have delayed the implementation of these new authorities. The ANHB realizes that home and community based care will decrease the need for institutional services in the long term. This will result in dramatic cost savings for the state. She urged the legislature to provide the medical assistance funding necessary to enhance these services. She stated that the ANHB supports SB 249 and HB 377. Ms. Johnson read the ANHB briefing paper on "Health Promotion and Disease Prevention" which gave many statistics that illustrate that almost one-third of all Native deaths are due to suicides, homicides, and unintentional injuries. She noted that many people are giving up smoking; however, they are turning to chewing. This is related to the increase in heart disease and stroke. She said that health prevention and information are ways to combat such problems. Ms. Johnson noted that the South Central Foundation has opened one of the first FAS treatment facilities in the country. Indian Health Services (IHS) supplies the majority of the funding. She said that additional help was needed. She stated support for funding of physicians assistant training programs. ANHB supports SB 231, HB 341 for reimbursement of services for physicians assistants in rural Alaska. She noted that physicians assistants are often economical. Ms. Johnson stated support for funding of mental health and substance abuse services. She emphasized that it is essential to continue efforts to resolve the Mental Health Lands Trust so that state funding remains intact for services currently provided. She expressed concern with the provision of adequate resources to reduce dependency on the Alaska Psychiatric Institute by allowing rural hospitals to provide inpatient psychiatric services without financial risk. She noted that Fairbanks was experimenting with this. She acknowledged the need to have an Alaska Psychiatric Institute (API); however, it does not seem to be the most effective means of care for rural people or people in Juneau. In conclusion, she stated that the problems that had been discussed were relevant to urban and rural Natives. Number 195 CHAIRMAN RIEGER asked how many beds would be needed at the API. KATHY JOHNSON could not answer with the exact number. ANNE WALKER stated that the number of beds at an API would be proportional to the number of designated psychiatric beds funded in other hospitals in the state. Ms. Walker noted that the choice would be between funding and locating all beds at API or less beds at API and operational funding be given to other hospitals for designated psychiatric beds. This would shift psychiatric beds from a centralized location to other hospitals. KATHY JOHNSON commented on the needs of the patient. When someone from rural Alaska is sent to API, they often do not seem to find there way back to rural Alaska. She stated that 60 percent of the people Brother Francis' shelter encounters are mentally ill. She indicated that such information supports having community based programs for adequate care. SENATOR SALO noted that HB 320 which deals with school health education has a Senate companion sponsored by Senator Ellis, SB 314. She explained that part of addressing health issues, especially for teenagers, would begin with them having access and the ability to deal with their own health issues. Two major obstacles for teenagers when they are attempting to take responsibility for their own health issues are transportation and access. She suggested locating health clinics and social service agencies near schools to eliminate the transportation and communication problems. KATHY JOHNSON noted that the South Central Foundation along with the Indian Health Service want to locate satellite clinics in communities with the highest native populations for better access to care for all clients. SENATOR SALO reiterated that also placing them near schools would create an even better situation. Number 097 SENATOR LEMAN asked what type of non-emergency services could be provided to a minor without parental consent, especially if these clinics are near schools. KATHY JOHNSON stated that ANHB is referring to family clinics. Ms. Johnson did not have an answer. SENATOR SALO said that the permission could be gotten. CHAIRMAN RIEGER asked where the Indian Health Services would fit in under SB 284 since they stated support from ANHB for the bill. ANNE WALKER pointed out that they had questions about the language, particularly the definition and visual picture of the market based single payer system. She noted that under SB 284, the health corporation would allow waivers for federally funded health programs. She expressed their opposition to lumping the Indian Health Services into any single payer program. The federal government has a trust responsibility to Alaska Natives who currently enjoy a government to government relationship. She cited health care services from the federal government as one of the benefits of this government to government relationship. She stated support of SB 284 except for the pursuit of the waiver for IHS. CHAIRMAN RIEGER asked if an exemption of IHS would be support for SB 284 for everyone except those people who can go to IHS. ANNE WALKER said no. She noted that the native hospitals are 50 percent funded by IHS with the remainder coming from private insurance companies and state Medicaid and Medicare programs. She asserted that they are a major player in SB 284. Since the IHS does not have a complete comprehensive benefit package, often they provide less than 50 percent of the funding, they do not provide long term care, and they provide minimal substance abuse services. KATHY JOHNSON explained that the Anchorage Health Corporation accepts third party payments which go back into the pool to provide care for those who cannot pay for care. TAPE 94-13, SIDE A Number 004 ANNE WALKER noted that the unique situation of delivering health services in Alaska is often not understood by others. She supported Alaska passing a health care reform bill before the federal government imposes their plan. CHAIRMAN RIEGER asked if Ms. Walker's support for SB 284 was due to their support for Alaska working and acting on health care reform or support for the single payer concept. ANNE WALKER noted that they had worked on the Health Resources and Access Task Force and the group that merged the two bills into SB 284. She stated that they support Alaska passing a health care reform bill and involving the state government in how private providers and insurance companies work in the health care system. She noted that Alaska currently has many health care systems that often clash. She said that they support components of SB 284, including the single payer system. She emphasized that they oppose pursuit of a waiver to merge IHS into the single payer system. The single payer system would be at odds with their current government to government relationship. SENATOR SALO said that as she understood, the Clinton plan would merge the IHS system as well as others. ANNE WALKER said no. The IHS system would be kept separate and would be enhanced to meet the comprehensive health care benefit package that the nation will have. SENATOR SALO asked why it would be kept separate. Number 065 ANNE WALKER explained that historically and throughout national law, Indian people have given up much, such as land and fishing rights to name a few. In return the federal government states in law that they will provide health care services through a trust relationship for the Indian people as a sovereign nation. She noted that the proposed merger in a state or national plan would end the direct government to government relationship as well as the federal trust. That is the major reason to keep IHS separate from any national or state plan. She reiterated that they are a player in state health reform because 50 percent of their funds would be effected. CHAIRMAN RIEGER thanked the representatives of the Alaska Native Health Board for their patience and their presentation. There being no further business before the committee, the meeting was adjourned at 3:12 p.m.