Legislature(2009 - 2010)CAPITOL 106

04/09/2009 03:00 PM House HEALTH & SOCIAL SERVICES

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
Heard & Held
Heard & Held
<Bill Hearing Rescheduled from 04/07/09>
HB 223-TRAINING FOR PSYCHIATRIC TREATMENT STAFF                                                                               
4:31:00 PM                                                                                                                    
CO-CHAIR KELLER announced  that the final order  of business would                                                              
be HOUSE  BILL NO.  223, "An  Act relating  to the  qualifications                                                              
for  residential  psychiatric treatment  center  caregiver  staff;                                                              
and providing for an effective date."                                                                                           
The committee took an at-ease from 4:31 p.m. to 4:36 p.m.                                                                       
4:36:57 PM                                                                                                                    
CO-CHAIR  KELLER   acknowledged  that   there  had   been  ongoing                                                              
discussion  and  negotiation  about  HB  223.   He  opened  public                                                              
4:39:12 PM                                                                                                                    
CO-CHAIR HERRON  moved to adopt the proposed  Committee Substitute                                                              
(CS)  for HB  223, Version  26-LS0842\C, Mischel,  4/8/09, as  the                                                              
working document.                                                                                                               
REPRESENTATIVE HOLMES objected for the purpose of discussion.                                                                   
MYRA MUNSON,  Attorney, The  Boys and Girls  Home of  Alaska, said                                                              
that the  Committee Substitute (CS)  set a new level  of caregiver                                                              
qualification  for   residential  psychiatric   treatment  centers                                                              
(RPTC).   She  noted  that there  were currently  three  caregiver                                                              
standards,  and she explained  the requirements  for each  option.                                                              
She  reported  that HB  223  allowed  for a  fourth  qualification                                                              
4:45:47 PM                                                                                                                    
REPRESENTATIVE  HOLMES  asked  for  a clarification  for  the  new                                                              
4:45:52 PM                                                                                                                    
MS.  MUNSON explained  that page  2,  line 26  should not  contain                                                              
(1),  and that  this would  allow  someone without  the four  year                                                              
combination of education  and experience to work  during the hours                                                              
that another qualified  caregiver with that four  year combination                                                              
was at work.                                                                                                                    
4:46:54 PM                                                                                                                    
MS. MUNSON referred  to Section 1 (c) and noted  that an amendment                                                              
would  mirror  the  regulation  except  to  also  allow  that  the                                                              
training  be approved  by  the  department, not  merely  provided.                                                              
She  pointed  to  Section  1(d) which  provided  a  definition  of                                                              
4:48:34 PM                                                                                                                    
REPRESENTATIVE  HOLMES  removed her  objection.    There being  no                                                              
further  objection,   Version  C   was  adopted  as   the  working                                                              
4:49:08 PM                                                                                                                    
PAT  HEFLEY,  Deputy Commissioner,  Office  of  the  Commissioner,                                                              
Department  of Health  and Social  Services (DHSS),  said that  he                                                              
recognized that the  health care workforce had one  of the highest                                                              
vacancy rates in  Alaska.  He emphasized that this  bill was for a                                                              
residential  psychiatric facility  for kids,  and that these  were                                                              
very tough  kids.  He  acknowledged that  the Bring the  Kids Home                                                              
program was  working very well, and  that about 66 percent  of the                                                              
kids were  home in Alaska.   He said  that many of  the facilities                                                              
had problems recruiting  employees to be in frequent  contact with                                                              
the  kids.   He said  that  DHSS had  a concern  with  the use  of                                                              
statute for  changes in  qualification standards.   He  noted that                                                              
the facilities  had the ability  to ask  for a variance,  and that                                                              
there was not a  need to drop the standard.   He expressed concern                                                              
that  incident  reports  would   increase.    He  said  that  only                                                              
recently  had he  been apprised  of  this urgency,  though he  was                                                              
aware  of a shortage  of staff.   He  said that  DHSS agreed  that                                                              
there was a  problem, but did not  agree with a change  in statute                                                              
as a solution.                                                                                                                  
4:57:09 PM                                                                                                                    
STACIE  KRALY, Chief  Assistant Attorney  General, Human  Services                                                              
Section, Civil  Division (Juneau),  Department of Law  (DOL), said                                                              
that she  had not seen  the CS, but  that the primary  concern for                                                              
DOL was that  there were already  processes in place to  solve the                                                              
issues.   She opined that  there were quite  a few  legal problems                                                              
with the original  bill.  She reserved any further  comments until                                                              
she had an opportunity to review the CS.                                                                                        
4:59:01 PM                                                                                                                    
REPRESENTATIVE  SEATON asked  what the optimal  limitation  to the                                                              
number of applicants was qualified within Section 1(b)(4).                                                                      
MR. HEFLEY said  that it was important to have  experienced staff,                                                              
and he  acknowledged that  experience was  learned.  He  expressed                                                              
his concern  for having  too many inexperienced  staff at  any one                                                              
given time.                                                                                                                     
5:01:46 PM                                                                                                                    
STACY  TONER,  Deputy Director,  Division  of  Behavioral  Health,                                                              
Department of  Health and Social  Services (DHSS), in  response to                                                              
Representative  Seaton, opined  that no  more than  10 percent  of                                                              
the staff should be this inexperienced.                                                                                         
5:02:09 PM                                                                                                                    
BEVERLY WOOLEY,  Director, Division  of Public Health,  Department                                                              
of   Health  and   Social   Services   (DHSS),  in   response   to                                                              
Representative Seaton,  said that  it was difficult  to determine,                                                              
and  this allowed  for the  variance process  to work  well.   She                                                              
explained that the  variance request came through  her office, and                                                              
it allowed review for the specific needs and situations.                                                                        
5:03:44 PM                                                                                                                    
CO-CHAIR KELLER  asked if there  was a comparable standard  in the                                                              
other states where Alaska had sent the youth.                                                                                   
MS. TONER,  in response to Co-Chair  Keller, said that  the Alaska                                                              
standard was comparable  to other states, but that  this was a big                                                              
change to  the existing  requirements.  She  noted that  there was                                                              
no reference to supervision in HB 223.                                                                                          
5:05:39 PM                                                                                                                    
CO-CHAIR   KELLER  offered   his  belief   that  supervision   was                                                              
addressed in Section 1(b)(4)(C).                                                                                                
MS. TONER  noted that  the wording,  "to work  at the  center only                                                              
during hours  in which an  individual is  on duty at  the center,"                                                              
did not address supervision.                                                                                                    
5:06:24 PM                                                                                                                    
REPRESENTATIVE  CISSNA said  that it  was her  desire to make  the                                                              
atmosphere  at  the   RPTCs  more  homelike.     She  related  her                                                              
experiences working  at Alaska Psychiatric  Institute (API).   She                                                              
described  the RPTC  current  atmosphere  as "much  more  severe,"                                                              
with  a  higher level  of  violence,  and  an increased  sense  of                                                              
hopelessness,  all  of  which  required  a much  higher  level  of                                                              
supervision.   She  stated that  she wanted  HB 223  to result  in                                                              
shorter, safer, healthier patient residential placements.                                                                       
5:10:05 PM                                                                                                                    
REPRESENTATIVE  LYNN  remarked  that his  year  teaching  severely                                                              
emotionally disturbed  kids was good  preparation for his  work at                                                              
the legislature.                                                                                                                
5:10:41 PM                                                                                                                    
CO-CHAIR KELLER asked  how many kids were in  RPTCs outside Alaska                                                              
and ready to come back to Alaska if beds were available.                                                                        
MS. TONER,  in response to Co-Chair  Keller, said that  there were                                                              
164 kids still outside Alaska.                                                                                                  
5:11:05 PM                                                                                                                    
REPRESENTATIVE  COGHILL referred  to Section  1(c), and asked  the                                                              
cost for the department to provide "training for caregivers."                                                                   
MS. TONER pointed out that the fiscal note was $400,000.                                                                        
5:11:59 PM                                                                                                                    
CO-CHAIR KELLER  asked if it was  a given that DHSS  provided this                                                              
training for RPTC staff.                                                                                                        
MS.  TONER  replied  that  there  was  a  residential  care  child                                                              
certification  training for  behavioral  rehab service  facilities                                                              
through the  Office of  Children's Services.   She explained  that                                                              
this  training  brought  staff   to  the  Medicaid  standards  and                                                              
Medicaid treatment  requirements.   She allowed that  the proposed                                                              
HB 223 would  also use this same  "Bring the Kids Home"  venue for                                                              
5:13:36 PM                                                                                                                    
REPRESENTATIVE  SEATON  referred  to  Section 1(b)  and  asked  if                                                              
paragraphs (1), (2), and (3) were each a separate requirement.                                                                  
MS. WOOLEY  said that four  different tiers of qualification  were                                                              
5:15:39 PM                                                                                                                    
MS. WOOLEY reiterated  that the variance process  was currently in                                                              
place  for   any  immediate  needs.     She  explained   that  the                                                              
regulatory  process allowed full  public process  and input.   She                                                              
expressed her concern with HB 223 as "a quick fix."                                                                             
5:16:47 PM                                                                                                                    
REPRESENTATIVE COGHILL  agreed that he was "no big  fan of pulling                                                              
regulation  out  and  putting  in   statutes,"  but  that  he  was                                                              
troubled  by  the difficulties  for  navigating  the system.    He                                                              
asked for suggestions to a remedy for hiring qualified care.                                                                    
MS. WOOLEY,  in response  to Representative  Coghill, agreed  that                                                              
the regulations  were overdue  for a revision.   She  offered that                                                              
the front line providers  should be involved in the  process.  She                                                              
also  suggested that  the university  system  could offer  classes                                                              
for  qualification.   She noted  the difficulty  in balancing  the                                                              
staff qualifications,  the safety and protection of  the kids, and                                                              
the priority to bringing the kids back to Alaska.                                                                               
5:20:47 PM                                                                                                                    
REPRESENTATIVE  SEATON  asked  how many  current  variances  there                                                              
were throughout the state.                                                                                                      
MS. WOOLEY  said that about 37-38  were granted over the  last few                                                              
5:21:48 PM                                                                                                                    
REPRESENTATIVE SEATON  commented that  only one variance  had been                                                              
allowed for a RPTC.                                                                                                             
MS. WOOLEY  said that there  had only been  one request,  and this                                                              
was a reason for the DHSS surprise to this recent crisis.                                                                       
5:22:12 PM                                                                                                                    
JIM  MALEY, President  & CEO,  Alaska  Children's Services  (ACS),                                                              
reported that ACS  employed 250 staff, with 96  direct care staff,                                                              
who would be  included under these regulations.   He expressed his                                                              
disagreement with the  statement from DHSS, and he  said that this                                                              
had  been a  long standing  challenge.   He  observed that  hiring                                                              
direct care  staff was always a  problem, and he gave  examples of                                                              
staff shortages and  the resulting problems.  He said  that he had                                                              
asked DHSS for a  variance, but that he was told  that it would be                                                              
denied.   He reported  that ACS had  developed a competency  based                                                              
training model  for residential  child care  workers.   He offered                                                              
the use  of this  model at  no cost  to the  state.  He  expressed                                                              
discomfort  at  this venue  for  discussion,  but he  offered  his                                                              
belief that  DHSS had not  viewed this  as a high enough  priority                                                              
to  make  changes to  the  regulation.    He reported  that  staff                                                              
shortages diminished  the opportunity to  bring more kids  back to                                                              
5:26:48 PM                                                                                                                    
MR. MALEY,  in response to Co-Chair  Keller, repeated that  he had                                                              
approached DHSS about  a variance, and was told that  it would not                                                              
be granted.                                                                                                                     
5:27:04 PM                                                                                                                    
REPRESENTATIVE CISSNA  asked about  the difficulty for  hiring and                                                              
retaining staff.                                                                                                                
MR.  MALEY replied  that there  were  a number  of factors,  which                                                              
included staff  pay.  He said  that an intensive  training program                                                              
could develop the  competency for staff to work with  kids, and he                                                              
opined  that there  was  a difference  between  this training  and                                                              
getting an education.                                                                                                           
5:30:27 PM                                                                                                                    
REPRESENTATIVE  SEATON  asked  what   the  most  common  Bachelors                                                              
degree was for applicants.                                                                                                      
MR. MALEY responded  that it would be either  psychology or social                                                              
work,   although    there   were   occasional    applicants   with                                                              
environmental and therapeutic recreation degrees.                                                                               
5:31:15 PM                                                                                                                    
REPRESENTATIVE  SEATON  asked  if  a  required  degree  in  social                                                              
services would be more restrictive for hiring.                                                                                  
MR.   MALEY  replied   that  it   would  not   be  a   significant                                                              
restriction.      He  commented   that   he  was   supportive   of                                                              
regulations, but  that he had  been frustrated with  the responses                                                              
he had received.                                                                                                                
5:32:27 PM                                                                                                                    
JEFF JESSEE, Chief  Executive Officer, Alaska Mental  Health Trust                                                              
Authority   (AMHTA),  Department   of  Revenue  (DOR),   expressed                                                              
concern  with the legislation.    He stated that  the points  were                                                              
well taken,  and that there was  agreement that the  licensing and                                                              
staff qualification  for RPTCs  needed to be  reviewed.   He noted                                                              
that  the  Fairbanks  RPTC had  not  asked  for  a variance.    He                                                              
suggested  that it  was  better to  work  through the  regulations                                                              
than to change through  statute.  He said that  the full assurance                                                              
from  DHSS to  quickly address  these issues  was most  important.                                                              
He expressed  concern with the minimum  level for staffing  in the                                                              
current CS.   He pledged  his support to  the Bring the  Kids Home                                                              
work group.                                                                                                                     
5:38:23 PM                                                                                                                    
KATE  BURKHART, Executive  Director,  Alaska  Mental Health  Board                                                              
(AMHB), explained the  background of the AMHB, and  noted that the                                                              
AMHB was  also an advocacy  group which solicited  public comments                                                              
on mental health  issues.  She stated that AMHB  could not support                                                              
the current  version of HB  223.  She  said AMHB had  not received                                                              
any  comments  from   parents  that  they  would   support  lesser                                                              
qualified  caregivers  at  the  RPTC.    She  suggested  that  the                                                              
committee  solicit  consumer  discussion.    She  said  that  AMHB                                                              
recognized the  necessity to balance  the provider  staffing needs                                                              
with the need for quality treatment.                                                                                            
5:40:42 PM                                                                                                                    
MS.  BURKHART   declared  that   AMHB  supported  the   regulation                                                              
process,  which  involved  the  public.   She  allowed  that  this                                                              
staffing  problem  was  pervasive  throughout  the  mental  health                                                              
arena.  She stated  that all the variables involved  in work force                                                              
shortages,  including wages,  benefits, and  stress, needed  to be                                                              
5:43:22 PM                                                                                                                    
MR.  HEFLEY  acknowledged  that   there  was  a  problem,  but  he                                                              
suggested that  resolution not be  through statute.  He  said that                                                              
there was not resistance  from DHSS.  He reiterated  that DHSS was                                                              
not aware that there was an issue.                                                                                              
5:44:20 PM                                                                                                                    
FRANCES PURDY, Executive  Director, Alaska Youth  & Family Network                                                              
(AYFN),  said  that  she  had  solicited   comments  from  parents                                                              
involved  with RPTCs.   She  reported that  parents had  commented                                                              
that the  turnover issue was  related to pay, not  qualifications.                                                              
She urged the  committee to continue with the  regulation process.                                                              
She stated that  this was not an issue of education,  but an issue                                                              
of competencies.   She shared  that the university  was developing                                                              
"best  practice  standards."    She  declared  that  many  issues,                                                              
including cultural  competency, the  stigma of mental  health, and                                                              
de-escalation  of confrontations,  were new  and required  ongoing                                                              
5:47:53 PM                                                                                                                    
MS. MUNSON  said that she  was sympathetic  to the DHSS  and AMHTA                                                              
concerns.    She  stated  that   this  problem  deserved  a  quick                                                              
solution.  She allowed  that DHSS had set very  high standards for                                                              
care providers,  which could  make it  difficult to find  adequate                                                              
caregivers.   She questioned  whether the  high standards  created                                                              
the best  protection for children,  as the issues were  most often                                                              
about: how  much protection, how much  money to spend,  and how to                                                              
find workers  willing to  do this difficult  work.   She explained                                                              
that, prior  to drafting  this legislation,  she had reviewed  the                                                              
states with Alaskan  children enrolled in RPTCs.   She stated that                                                              
the Alaska  standards were  higher than any  of the  other states,                                                              
and she offered  some comparisons.  She declared that  she was not                                                              
trying  to  minimize  the  important and  essential  role  of  the                                                              
direct care  providers.   She stated that  the original  intent of                                                              
the  bill was  to exactly  replicate the  existing regulation,  so                                                              
that there  would not be any  service disruption, and then  to add                                                              
an additional  standard.  She  referred to the amendment  [labeled                                                              
C.3] [Included  in the  members' packets.]  and explained  that it                                                              
included on-site  supervision, or  mentorship, by someone  who met                                                              
the  specifically listed  requirements.   She  reiterated that  it                                                              
was the experience  of residential child care in  the setting, not                                                              
the  education, which  was most  critical.   She  said that  these                                                              
entry  level  jobs  often  led   to  an  increased  interest,  and                                                              
continued education.   She noted that the ratio  of supervisors to                                                              
caregivers was one to six.                                                                                                      
5:59:15 PM                                                                                                                    
MS.  MUNSON  said   that  variances  were  on   an  individual  by                                                              
individual basis.   She said that  any RPTC which was  planning to                                                              
open could  not ask for  a variance until  they were hiring.   She                                                              
explained  the importance  for any  new RPTC  to be  aware of  the                                                              
qualification guidelines  in advance.  She acknowledge  the desire                                                              
of the  DHSS to make  the regulatory process  a priority,  but she                                                              
noted  that the regulations  had  been in effect  since 1998,  and                                                              
that all  the testifiers  to the  process had  suggested that  all                                                              
the  levels of  care needed  to be  reconsidered.   She cited  the                                                              
difficulty for  ACS to maintain  all of  their units, even  with a                                                              
large  workforce   to  draw  experienced  personnel   from.    She                                                              
expressed the  urgency for action,  and she expressed  her concern                                                              
that  Alaska  was   sending  kids  to  other  states   with  lower                                                              
standards  than  Alaska.   She  suggested  to fix  this  caregiver                                                              
problem  immediately,  and then  to  move  forward and  deal  with                                                              
other problems.   She suggested  making this a temporary  bill for                                                              
one year,  with a  provision for  DHSS to  undertake a  regulatory                                                              
process.    She noted  that  this  would allow  for  uninterrupted                                                              
care,  and  would  give  guidance   for  the  development  of  new                                                              
6:07:19 PM                                                                                                                    
CO-CHAIR KELLER closed public testimony.                                                                                        
6:08:10 PM                                                                                                                    
REPRESENTATIVE COGHILL  noted that there were amendments  still to                                                              
be proposed  which could affect the  fiscal note.  He  stated that                                                              
he wanted  to keep moving forward  with the legislation,  but that                                                              
he was hesitant about the approach.                                                                                             
6:08:47 PM                                                                                                                    
REPRESENTATIVE  SEATON reflected  that there  were problems  which                                                              
had existed  for years.  He  said that the legislature  made laws,                                                              
not regulations.   He did not want to rush forward,  but preferred                                                              
to hear more suggestions for options within the variance system.                                                                
6:10:42 PM                                                                                                                    
REPRESENTATIVE  CISSNA  said  that   the  serious  problems  began                                                              
decades ago.   She  explained that previously  when there  were no                                                              
services in Alaska,  the kids were sent out of state.   She opined                                                              
that, even  now, state  policy did  not give  a priority  to these                                                              
issues.    She stated  that  the  preventative  approach  achieved                                                              
great results at  a fraction of the cost.  She  counseled to "take                                                              
the time  to do this  right."  She  offered her belief  that there                                                              
was a pressure  "to fill those  beds."  She emphasized  that there                                                              
was not a rush  for quality or for safety of  kids.  She suggested                                                              
that the House  Health and Social Services Standing  Committee put                                                              
pressure on DHSS for solutions.                                                                                                 
[HB 223 was held over.]                                                                                                         

Document Name Date/Time Subjects
CSHB 188 Sponsor Summary version N.doc HHSS 4/9/2009 3:00:00 PM
HB 188
CSHB 188 Version N.PDF HHSS 4/9/2009 3:00:00 PM
HB 188
HSS188pkt.PDF HHSS 3/26/2009 3:00:00 PM
HHSS 4/9/2009 3:00:00 PM
HB223pkt.PDF HHSS 4/9/2009 3:00:00 PM
HB 223
HB168pkt.PDF HHSS 4/9/2009 3:00:00 PM
HB 168
HB 188 Sectional Version N.PDF HHSS 4/9/2009 3:00:00 PM
HB 188