Sunset review of the Nursing Care Institution Administrators and Assisted Living Facility Managers Board

              Arizona House of Representatives
House Majority Research
MEMORANDUM
Kristine Stoddard~
Assistant Legislative Research Analyst
(602) 926-5299
1700 W. Washington
Phoenix, AZ 85007-2848
FAX (602) 417-3140
To: Joint Legislative Audit Committee
cc: Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Re: Sunset Review of the Nursing Care Institution Administrators and Assisted Living
Facility Managers Board
Date: December 2, 2005
Attached is the final report ofthe sunset review ofthe Nursing Care Institution Administrators
and Assisted Living Facility Managers Board, which was conducted by the Senate Health and
House ofRepresentatives Health Committee ofReference.
This report has been distributed to the following individuals and agencies:
Governor ofthe State ofArizona
The Honorable Janet Napolitano
President ofthe Senate
Senator Ken Bennett
Senate Members
Senator Jim Waring, Vice-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
Speaker ofthe House of Representatives
Representative Jim Weiers
House Members
Representative Rick Murphy, Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Nursing Care Institution Administrators and Assisted Living Facility Managers Board
Department of Library, Archives & Public Records
Auditor General
Senate Republican Staff
Senate Research Staff
Senate Democratic Staff
House Majority Staff
House Research Staff
House Democratic Staff
Senate Health and House ofRepresentatives Health
Committee ofReference Report
Nursing Care Institution Administration andAssisted Living Facility Managers Board
Date: December 2, 2005
To: Joint Legislative Audit Committee
Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Background
Pursuant to Arizona Revised Statutes (ARS) §41-2953, the Joint Legislative Audit
Committee (JLAC) assigned the sunset review of the Nursing Care Institution
Administration and Assisted Living Facility Managers Board (Board) to the Senate
Health and House of Representatives Health Committee ofReference.
The Nursing Care Institution Administration and Assisted Living Facility Managers
Board was established by the Legislature with Laws 1975, Chapter 141, §13. The
Board's mission is to protect the health, welfare, and safety of Arizona citizens who seek
and use the -services of nursing care institution administrators and assisted living facility
managers. The Board is responsible for licensing nursing care institution administrators
and certifying assisted living facility managers. Statute requires nursing care institutions
be operated by Board licensed administrators and that assisted living facilities be
operated by Board certified managers. The Board must adopt rules for the examination
and licensure of nursing care administrators and the examination and certification of
assisted living facility managers. This includes approving continuing education courses
for managers and administrators, which enables them to achieve the statutory required
hours for renewal of licenses and certifications. The Board currently licenses, certifies
and regulates 2,021 assisted living facility managers and 379 nursing horne
administrators.
Committee ofReference Sunset Review Procedures
The Committee of Reference held one public meeting on November 8, 2005 to review the
Board's responses to the sunset factors as required by ARS §41-2954, subsections D and
F, and to hear public testimony.
Committee ofReference Recommendations
The Committee of Reference recommends continuing the Nursing Care Institution
Administration and Assisted Living Facility Managers Board for five years, pending the
findings of the Auditor General's report due in December of2005.
Attachments:
1. Sunset report requirements pursuant to ARS §41-2954, subsections D andF.
2. Meeting Notice.
3. Minutes of the Committee ofReference meeting.
Arizona House of Representatives
House Majority Research
MEMORANDUM
Kristine Stoddard ~
Assistant Legislative Research Analyst
(602) 926-5299
1700 w. Washington
Phoenix, AZ 85007-2848
FAX (602) 417-3140
To: Members ·of the House and Senate Health Committees of Reference
Re: Sunset Review of the Nursing Care Institution Administrators and Assisted Living
Facility Managers Board
Date: October 26, 2005
The Nursing Care Institution Administrators and Assisted Living Facility Managers Board (Board) is
scheduled to sunset July 1, 2006. The following is a brief description ofthe history and duties ofthe
Board, as well as the Board's response to the sunset questionnaire. A public meeting is scheduled for
November 8, 2005 to allow you to ask questions of the Board, take public testimony, and make a
final recommendation on the Board's continuation. If you have any questions or need further
assistance, please feel free to contact me.
AGENCY MISSION AND mSTORY
-
The Board was established by the Legislature with Laws 1975, Chapter 141, §13. The Board's
mission is to protect. the health, welfare, and safety of Arizona citizens who seek and use the
services ofnursing care institution administrators and assisted living facility managers.
The Board is responsible for licensing nursing care institution administrators and certifying assisted
living facility managers. Statute requires nursing care institutions be operated by Board licensed
administrators and that assisted living facilities be operated by Board certified managers.
October 26, 2005
Nursing care institutions provide care for people who need nursing services on a continuing basis, but
who do not require hospital care or care under the daily direction of a physician. These facilities are
often called nursing homes and sometimes are referred to as skilled nursing facilities. Assisted living
facilities are residential care institutions that provide or contract to provide supervisory, personal, or
directed care on a continuing basis for people who do not require continuous nursing care. These
facilities have staff who assist elderly, disabled, or other residents with eating, personal hygiene, and
other activities.
ORGANIZATION AND DUTIES
The Board consists of eleven members who are appointed by the Governor. This number was
increased last session with the passage of SB 1358 from nine to eleven members. According to the
Board, since August 2005, the Board has worked with the Governor's office to ensure the Board
positions are appropriately filled. The Board must include one administrator of a nonprofit faith
based skilled nursing facility, one administrator of a proprietary skilled nursing facility, two
managers of an assisted living center who are not currently affiliated with a nursing care institution,
two managers of an assisted living horne who are not currently affiliated with a nursing care
institution, one manager at large not currently affiliated with a nursing care institution, two members
which are representative of the professions concerned with the care and treatment of the chronically
ill or infirm elderly patients and two public members not currently affiliated with a nursing care
institution or an assisted living facility. Statute specifies that noninstitutional administrative
members of the Board may not have a direct fmancial interest in nursing care institutions or assisted
living facilities. Members are appointed for two-year terms and no member may serve for more than
two consecutive terms. Statute requires that the Board meet at least twice a year and states that
members of the Board are eligible for compensation for each day spent performing their duties as
Board members.
According to Arizona Revised Statutes CARS) §36-446.03, the Board may adopt, amend or repeal
reasonable and necessary rules and standards in relation to performing their duties and must apply
appropriate techniques for determining whether a person meets the qualifications to be licensed and
certified as an administrator and manager respectively. Additionally, the Board must adopt rules for
the examination and licensure ofnursing care administrators and the examination and certification of
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October 26, 2005
assisted living facility managers. This includes approving continuing education courses for
managers and administrators, which enables them to achieve the statutory required hours for renewal
of licenses and certifications. The Board is statutorily permitted to adopt nonrefundable fees and to
elect officers. The Board is authorized to conduct investigations, hearings and other proceedings
concerning violations of the rules adopted by the Board and statute relating to the Boarq.. ARS §36­446.03
also permits the Board to employ persons to provide investigative, professional and clerical
assistance as required to perform its powers and duties. The Board is permitted to appoint review
committees to make recommendations concerning enforcement matters.
According to the Board, since June 2005, the backlog from FY 2003 of complaints has been reduced
to 4. Uninvestigated complaints from FY 2004 have been reduced to 10. FY 2005 complaints that
have not been investigated have been reduced to 34. The Board currently licenses, certifies and
regulates 2021 assisted living facility managers and 379 nursing home administrators.
FISCAL ISSUES
ARS §36-446.08 establishes the Nursing Care Institution Administrators' Licensing and Assisted
Living Facility Managers' Certification Fund (Fund). Ten per cent of the monies collected by the
Board are deposited into the State General Fund, while the remaining ninety per cent are deposited
into the Fund. Monies that are collected as a result of civil penalties must be deposited into the State
General Fund. According to the Appropriations Report published by the Joint Legislative Budget
Committee, in Fiscal Year 2005, the Board was authorized five full-time employees (FTE) and an
operating budget of $370,000. According to the data submitted by the Board, the Board reduced its
staff from five FTEs to three FTEs. The Board eliminated the office manager and administrative
assistant. The three remaining FTEs include the Executive Director, Investigator and the Licensing
Coordinator.
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October 26, 2005
LEGISLATTVEISSUES
In 2005, the Legislature passed Senate Bill 1358 which enabled the Board to discipline
administrators and managers after their license or certificate had expired. It also increased the Board
membership from nine to eleven members. SB 1358 set Board member terms at two-year terms and
required assisted living facility managers to document paid health related work experience.
The Board is currently requesting legislation to increase the license fee limits for both administrators
and managers and increase other fees by proportional amounts. Manager fee limits have not
increased since 1991 and administrator fee limits were last raised in 1998. Currently, both fees are at
the maximum limits statutorily permitted.
ADDITIONAL BACKGROUND
Lindsey Norris, Executive Director of the Arizona Association ofHomes and Housing for the Aging
(AzAHA) stated that she has not identified any current problems but is aware that the Board is
working to fill vacant seats. She also stated that AzAHA continues' to support the Board and if she
becomes aware of any issues, she will contact staff.
Kathleen Collins Pagels, Executive Director of the Arizona Health Care Association, speaking.on
behalfofherself only, stated that she has been attending the recent Board meetings and has been very
impressed with the progress the Board has made. According to Ms. Pagels, the investigation backlog
seems to have diminished. She also stated that the new Executive Director, Alan Imig, seems to be
very qualified and has a handle on things.
Ms. Pagels believes there may be challenges with leadership due to the fact that several board
members will no longer be eligible because ofthe changes done in the 2005 Legislative Session. Ms.
Pagels stated that she had received feedback from the Skilled Nursing Facility (SNF) profession
regarding the number of assisted living representatives on the Board versus the number of skilled
nursing facility managers. The SNF believes that the two are out of proportion and this could'
become an issue given the differential in education and clinical training requirements when one's
license is on the line. According to Ms. Pagels, skilled nursing facility administrators must have
completed a Master's degree in health care of LTC administration or a certified Administrator in
Training Program and assisted living managers are required to have a high school diploma. Ms.
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October 26, 2005
Pagels stated that there is no federal funding for assisted living but there is federal funding for eMS
for the SNF licensees.
Ms. Pagels has become aware of the concerns in changing statute to include "faith based" in regards
to the membership ofthe Board requiring one member to be an administrator from a non-profit faith
based skilled nursing facility. She said that some believe this distinction to be in appropriate. Ms.
Pagels mentioned that there is some thought to separating the skilled nursing facility licensure and
assisted living. She believes that the fmancial problems the Board faced began when the certification
ofassisted living managers was added to the same article.
Ms. Pagels hopes that the Board will continue to grow in strength and capacity and will not be
terminated.
5
Allen Imig
Governor Executive Director
Janet Napolitano
BOARD OF EXAMINERS OF NURSING CARE INSTITUTION ADMINISTRATORS AND
----------------A-SSISTED LIVING FACILITYMANAGERS
1400 West Washington, Suite B - 8
Phoenix, Arizona 85007
(602)364-2273 phone
(602)542-8316 fax
Email: information\aJnciabd.state.az.us
Website: www.nciabd.state.az.us
September 7, 2005
Representative Rick Murphy
Chair, Health Committee ofReference
Arizona House of Representatives
1700 W.Washington
Phoenix, AZ 85007
RE: Sunset factors pursuant to A.R.S. §41-2954
Dear Representative Murphy:
In accordance with the provisions of A.R.s. §41-2954 and in response to your letter dated
June 30, 2005, I offer the following response to the sunset consideration factors as
follows:
1. The Objective and purpose in establishing the agency.
The Board was created in 1975 to protect the public's health, safety and welfare by
licensing and regulating nursing care institution administrators and also in response to
federal requirements that each state must license administrators of nursing homes in order
to receive certain federal Medicare funds. In 1990, the Board's statutes were amended to
add the responsibility for certifying and regulating adult care home managers, renamed in
1998 to assisted living facility managers.
The Board's mission is to "protect the health, welfare, and safety ofArizona citizens who
seek and use the services of nursing care institution administrators and assisted living
facility managers." To accomplish this mission, the Board has established three goals: 1)
to improve agency operations relating to complaint investigations to ensure consistent
and timely enforcement of statutes and rules regulating nursing care institution
Page 1 of9
administrators and assisted living facility managers; 2) to ensure that licenses and
certificates are processed in a timely and efficient manner; and 3) to ensure that agency
operations are effective and efficient.
2. The effectiveness with which the agency has met its objective and purpose
and the efficiency with which it has operated.
Using the Auditor General's report of2004 as a guide, the Board has focused its efforts
to be effective and efficient in meeting the agency objectives in all areas.
The Board has implemented policies and procedures regarding complaint investigations
that include timeframes at each stage. Management reports are prepared monthly and
presented at the Board meetings. These reports identify any abuse and neglect cases, the
number of open investigations, and which fiscal year they were opened.
Since June 2005, the backlog of fiscal year 2003 complaints that have not been
investigated has been reduced to 4. Uninvestigated complaints from Fiscal year 2004
have been reduced to 10. Fiscal year 2005 complaints that have not been investigated
have been reduced to 34.
This was accomplished in several ways. By eliminating duplication and redundancy of
reports, efficiency was increased without compromising the thoroughness of the report or
investigation. By allowing the investigator to better utilize his time investigating the
complaint and dictating his reports, and then arranging for clerical support to type the
dictated report. The Board was also able to arranged short term assistance of
investigators from another state agency to help with several ofthe backlog of cases.
Administrative changes were implemented with regard to initial licensing and
certification so the process aligns directly to the timeframes and rules. Each step in the
process is now monitored with written notices given when required. This will help
ensure that all temporary and initial licensing and certification is completed within the
established timeframes.
Other changes include giving the manager's exarnination monthly, instead of every other
month. This gives the applicants more opportunities to successfully complete the
certification process, within the timeframes. Also, test scoring equipment was upgraded
to reduce staff time and increase efficiency.
The Board has reduced staff from 5 FTE's to 3 FTE's. Included in the reduction are the
office manager and administrative assistant. The three remaining personnel are the
Executive Director, Investigator, and Licensing Coordinator.
Page 2 of9
As part ofthe reduction in staff and efficiency savings, the Board now utilizes the
services of the ADOA State Boards OffiQe for mail processing, cash-handling, deposits,
claims, travel claims, payroll, procurement, and personnel records.
3. The extent to which the agency has operated within the public interest.
The Board holds meetings every month that are always open to the public. The meetings
are properly noticed with agendas posted. The meeting dates, time and location are
posted on our website.
The website also allows the public to look up any statute or rule related to nursing care
institution administrators and assisted living facility managers. Complaint forms and
information about the complaint process are also available.
The website allows the public to look up the status of an administrator or manager and
has basic information about each licensee or certificate holder. As resources become
available the Board intents to improve this website to include viewing disciplinary
actions.
Also, as resources become available, to better inform the public, the Board would
improve the website to include Board meeting minutes, agendas, and up to date statistical
information.
In response to the Auditor General's recommendations to make it easier for the members
ofthe general public to serve on the Board, Senate Bill 1358 was passed. The bill
redefined the qualifications of each Board member position and increased the Board from
9 to 11.
Since the law went into effect on August 12, 2005, the Board has worked with the
Governor's office to ensure the Board positions are appropriately filled.
4. The extent to which rules adopted by the agency are consistent with the
legislative mandate.
The Governor's Regulatory Review Council (GRRC) reviewed the Board's rules in
August 2004 and determined the Board needs to amend some ofthe rules to ensure they
are consistent with statutes. On June 30, 2005, at GRRC's request, the Board outlined a
step by step plan to accomplish the rule changes approved in the five-year review report.
The Board outlined a time-table for each article, with a planned end date ofDecember 31,
2007. The Board also has an interagency service agreement (lSA) for a rule writer to
assist with this proj ect.
Page 3 of9
The Auditor General's report points out the Board needs to define the work experience it
will accept to satisfy the certification requirement for managers. Senate Bill 1358
modified A.R.S. §36-446.04(B)(4) that an applicant must have completed 2080 hours of
paid, health related work experience within the last five years, instead of twelve months
ofwork experience in a health related field within the preceding five years. This
modification helped to document the work experience but will still have to define what
experience is acceptable. Defining work experience in rules falls under Article 4 and is
the first Article to be addressed in the plan approved by GRRC.
5. The extent to which the Board has encouraged input from the public before
adopting its rules, and the extent to which it has informed the public as to its
actions and their expected impact on the public.
The Board followed all requirements for noticing and public comments when it amended
its rules concerning fees for administrator licenses and manager certificates in fiscal year
2004. This included filing a formal notice ofrulemaking with the Secretary of State's
Office and providing a period ofpublic review and comment.
The Board has complied with the State's open meeting laws. The Board has posted
public meeting notices at least 24 hours in advance at the required location, made
agendas available to the public and maintained meeting minutes. The Board also has a
call to the public at each ofits meetings.
6. The extent to which the agency has been able to investigate and resolve
complaints that are within its jurisdiction.
The Board has appropriated and funded one FTE investigator. In addition, the Executive
Director is an experienced investigator and can assist as time allows. Since the Auditor
General's last report, the Board has reduced the number ofuninvestigated complaints
from FY2003 to 4 and FY2004 to 10. Ofthe FY 2005 complaints 34 out of61 remain as
open investigations. As the investigations are completed, they are presented to the Board
to be reviewed and adjudicated. Licensees or certificate holders who the Board found in
violation of the statutes or rules are finalized through a consent agreement or formal
hearing through the Office ofAdministrative Hearings.
In May 2005, the Board approved a new policy and procedure that clarifies the
investigative position, expectations, and investigative process from intake to final
decision.
Page 4 of9
7. The extent to which the Attorney General or any other applicable agency or
state government has the authority to prosecute actions under the enabling
legislation.
A.R.S.. §41-192 authorizes the Attorney General's Office to prosecute actions and
represent the Board. The Board is currently represented by one part-time Assistant
Attorney General.
8. The extent to which the agency has addressed deficiencies in its enabling
statutes that prevent it from fulfilling its statutory mandate.
The Board's statutes have been amended several times in the past with the most recent
being in 2005 with the passage of Senate Bill 1358. It enabled the Board to discipline
administrators and managers after their license or certificate had expired. It reconfigured
the qualifications of the Board and increased Board membership to 11. It also adjusted
the Board member terms to two-years, and defmed disqualification and termination. The
amendment also modified qualifications for assisted living facility managers requiring
them to document paid health related work experience.
Part of the legislation that was not successful in 2005 was a fee limit increase.
The Board will once again seek legislation to increase the fee limits for both
administrators and managers and increase other fees by proportional amounts.
9. The extent to which changes are necessary in the laws of the agency to
adequately comply with these factors.
The manager fee limits have not increased since they were promulgated in 1991. The
administrator fee limits were last raised in 1998. Both administrator and manager fee
limits are at the maximum limit pursuant to a rule change in April 2004.
The Board has increased efficiency and reduced staff from 5-FTE's to 3-FTE's to reduce
expenditures and achieve as close as possible a zero sum balance with projected
revenues. Without a fee limit increase in 2006 additional savings will have to be
achieved by February 2007 to keep from going negative.
The Board currently licenses, certifies and regulates 2021 managers, 379 administrators.
It processed 773 manager applications and 49 administrator applications in FY2005.
There were also 61 complaint investigations opened. The Board also approves
continuing education courses so managers and administrators receive up to date
information and are able to achieve the statutory required hours for renewal. To
accomplish the Board's mission to protect the public, adequate resources need to be in
place.
Page 5 of9
10. The extent to which the termination of the agency would significantly harm
the public health, safety or welfare.
Terminating the Board would harm the public health, safety, and welfare as the Board is
responsible for licensing administrators, certifying managers, and investigating and
adjudicating complaints against administrators and managers. Without state laws
establishing educational and competency standards, the public could be subject to
unqualified, incompetent or unscrupulous administrators and managers. As the state
grows and the population ages, the number of administrators and managers staffing
institutions and facilities is anticipated to increase.
Termination of the Board would disqualify the state from participating in
Medicare/Medicaid funding programs, which would directly affect the public by
eliminating a significant amount of federal funds.
11. The extent to which the level of regulation exercised by the agency is
appropriate and whether less or more stringent levels of regulation would be
appropriate.
The current level of regulation exercised by the Board of Examiners ofNursing
Institution Administrators and Assisted Living Facility Managers is appropriate.
12. The extent to which the agency has used private contractors in the
performance of its duties and how effective use of private contractors could
be accomplished.
The Board has used private contractors to perform certain services. For example, the
Board has contracted to support its website, database, computer system, rule
development, and transcription services.
Additional responses to the following questions were requested.
1. An identification of the problem or the needs that the agency is intended to
address.
Below are areas the Board has identified as problems or needs that are in the process of
being addressing, or need to be addressed.
A. Bringing current the backlog ofuninvestigated complaints for the Board to review
and adjudicate. Also, keep the standard of 180 days or less to resolve a
complaint.
B. Address financial needs, both on the expenditure side as well as the revenue side.
Page 6 of9
C. Improve public information availability and accuracy.
D. Closer oversight by the Board.
E. Rule updates and revisions
2. A statement, to the extent practicable, in quantitative and qualitative terms,
of the objectives of such agency and its anticipated accomplishments.
As outlined in #2 above, the Board is well on its way in addressing the backlog of
investigations. Since June 2005, the backlog of fiscal year 2003 complaints that had not
been investigated has been reduced to 4. Fiscal year 2004 complaints that had not been
investigated have been reduced to 10. Fiscal year 2005 complaints that have not been
investigated have been reduced to 34. The objective is to complete all investigations for
unresolved complaints that originated in FY2005 by February 28,2005.
To meet reasonable financial constraints and still meet the objective above, permanent
NCIA personnel was reduced to three FTEs. An Executive Director, Investigator, and
Licensing Coordinator. To accomplish this, certain administrative functions have been
outsourced. Fiscal and administrative functions (cash receipt processing, deposits, claims
preparation, timekeeping, procurement, personnel records etc.) will be transferred from
the Central Services Bureau (CSB) ofthe General Accounting Office to the State Boards
Office (SBO) ofthe Department of Administration. This will enable NCIA to take
advantage of the clerical services of the SBO, eliminating the need for NCIA staff
While SBO services will cost more than CSB services (by approximately $11 thousand
per year), SBO services will cost significantly less than the combination of CSB services
and anFTE to perform clerical and financial services within NCIA.
Moreover, additional operational economies will be sought and aggressively pursued.
Among these would be alternative approaches to rule writing, an elimination of out-of­state
travel, a prohibition against State-paid attendance at conferences. Also, a reduction
in office related services that include, unused or unneeded telephone lines, services, and
e-mail accounts.
Reintroduce legislation to increase, manager and administrator licenses fee limits and to
increase other fees by proportional amounts.
In order to continue to provide professional oversight and regulation ofthis industry, fees
for nursing care institution administrators and assisted living facility managers must be
increased. Numerous fmancial projections have been produced, which, without
exception, have pointed to this inescapable conclusion.
Page 7 of9
The Board understands, though, that for such an increase to be palatable to the profession
and to the Legislature, NCIA must, fIrst, prove itselfto be fIscally well managed and has
taken aggressive steps to that end.
Even though the Board currently has limited fInancial resources, the public must have
accurate and accessible information. Currently the Board's website allows the public to
look up the status of an administrator or manager, and any statute or rule related to the
NCIA Board. Complaint forms and information about the complaint process are also
available. Information can also be obtained by calling the Board office.
As resources become available, the Board would improve the website to include Board
meeting minutes, agendas, publish an E-newsletter, and view disciplinary actions.
Currently, the Board receives monthly, financial reports, complaint investigation reports
and licensing reports.
The Board proposed an updated timeline and plan that was approved by GRRC in July
2005. Also in July, 2005, the Board has contracted with ADOA for rule writing
assistance. The timeline and plan covers revisions and amendments to all four Articles of
the Board's rules.
3. . An identification of any other agencies having similar, conflicting or
duplicate objectives, and an explanation of the manner in which the agency
avoids duplication or conflict with other such agencies.
There is no other agency in Arizona whose scope ofpractice duplicates or overlaps the
practice of nursing care institution administrators or assisted living facility managers.
4. An assessment of the consequences of eliminating the agency or of
consolidating it with another agency.
Terminating the Board would harm the public health, safety, and welfare as the Board is
responsible for licensing administrators, certifying managers, and investigating and
adjudicating complaints against administrators and managers. Without state laws
establishing educational and competency standards, the public could be subject to
unqualifIed, incompetent or unscrupulous administrators and managers. As the state
grows and the population ages, the number of administrators and managers staffIng
institutions and facilities is anticipated to increase.
Termination of the Board would disqualify the state from participating in
Medicare/Medicaid funding programs for which the State receives significant amounts of
federal funds.
Page 8 of9
Because the Board is a 90/10 agency it is funded exclusively by the profession. There is
no general fund money appropriated to its existence. However, the Board returns 10% of
its revenues to the States general fund. Termination would reduce revenue to the State
general fund.
If the Board was consolidated with another state agency, the agency would lack the
critical expertise, insight, and involvement of practitioners and consumers. Without a
Board comprised ofpractitioners, the state would be faced with hiring consultants for this
expertise. In addition, another agency may lack staff and resources to carry out the
mission ofthe Board.
On behalf of the Arizona Board of Examiners ofNursing Care Institution Administrators
and Assisted Living Facility managers, I thank you for the opportunity to respond to
these questions. If you have additional questions, or require clarification, please contact
me at 602-542-8156 or bye-mail atallen.imig@nciabd.state.az.us
Respe.ctful.~, /
~~..
Allen hnig
Executive Director
Attachments: Financial projections
GRRC Timeline
Page 9 of9
Interim agendas can be obtained via the Internet at http://www.azleg.state.az.us/lnterimCommittees.asp
ARIZONA STATE LEGISLATURE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH
COMMITTEE OF REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Date:
Time:
Place:
Tuesday, November 8,2005
9:00 a.m.
House Hearing Room 1
AGENDA
1. Call to Order - Opening Remarks
2. Health Facilities Authority
• Presentation by the Health Facilities Authority
• Public Testimony
• Discussion and Recommendations by Committee of Reference
3. Medical Radiologic Technology Board of Examiners
• Presentation by the Medical Radiologic Technology Board of Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
4. Nursing Care Institution Administration and Assisted Living Facility Managers Board
• Presentation by the Nursing Care Institution Administration and Assisted Living
Facility Managers Board
• Public Testimony
• Discussion and Recommendations by Committee of Reference
5. Board of Homeopathic Medical Examiners
• Presentation by the Board of Homeopathic Medical Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
6. Arizona Alliance of Surgical Specialists
• Presentation by the Arizona Alliance of Surgical Specialists
• Public Testimony
• Discussion and Recommendations by Committee of Reference
7. Arizona Association for Home Care
• Presentation by the Arizona Association for Home Care
• Public Testimony
• Discussion and Recommendations by Committee of Reference
8. Arizona Midwifery Institute
• Presentation by the Arizona Midwifery Institute
• Public Testimony
• Discussion and Recommendations by Committee of Reference
9. Adjourn
Members:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
10/31/05
jmb
Representative Rick Murphy, Co-Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
People with disabilities may request reasonable accommodations such as interpreters,
alternative formats, or assistance with physical accessibility. If you require accommodations,
please contact the Chief Clerk's Office at (602) 926-3032, TOO (602) 926-3241.
ARIZONA STATE LEGISLATURE
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH COMMITTEE OF
REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND
.ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Minutes of the Meeting
Tuesday, November 8, 2005
9:00 a.m., House Hearing Room 1
Members Present:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Left
Members Absent:
Representative David Bradley
Staff:
Beth Kohler, Senate Health Research Analyst
Elizabeth Baskett, House Health Research Analyst
Representative Rick Murphy, Co-Chair
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Co-chairman Murphy called the meeting to order at 9:12 a.m. and attendance was
noted.
Presentation by the Health Facilities Authority
Blaine Bandi, Executive Director, Health Facilities Authority (HFA), stated that his
organization was established in 1977 to issue bonds exempt from income tax on the
Authorities interest which enables them to get lower interest rates. He explained that the
Authority would then loan their proceeds to health care facilities at lower rates than the
healthcare facilities would receive from banks. Mr. Bandi remarked that the Authority
provided low cost loans for rural and underserved healthcare facilities.
He stated that rural communities that have benefited from the program included:
• Flagstaff
• Kingman
• Prescott
• Wickenburg
• Douglas
• Springerville
• Page
• Sisbee
• Camp Verde
• Fort Mojave
• Peach Springs
• Sacaton
• Elfrida
• Morenci
• Ajo
• S1. Michaels
Mr. Sandi remarked that the Health Facilities Authority was not a regulatory agency and
that it existed solely to improve the health care for the residents of Arizona through the
financing of critical health care projects. He remarked that failure to continue the
Authority would deprive the State's health care providers of a needed source of tax
exempt financing. He respectfully requested the Committee of Reference recommend
the Arizona Health Facilities Authority be continued for ten years.
In response to Senator Cannell's question about the possibility of a hospital not paying
their loan back, Mr. Sandi told the Committee that since the inception of the HFA in
1977, this had only occurred once. He remarked that payments by that hospital were
still being made to HFA. Mr. Sandi added that the residents of the State have no legal
obligation to back up those bonds because they were issued solely on the credit of the
institution.
Representative Knaperek asked Mr. Sandi to list the seven directors for HFA and he did
so as follows:
1. Bruce Gulledge, health care underwriter who does financing for health
care institutions across the country.
2. Donald Shropshire, former hospital administrator; Tucson Medical
Center.
3. Jennifer Ryan, community health center director from Southern Arizona.
4. Rufus Glasper, Chancellor of the Maricopa County Community College
District.
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5. William Emerson, City Attorney for the City of Peoria.
6. Susan Straussner, Community Health Nurse from Parnell County.
7. Steven Russo, Sond Attorney based in Tucson.
In response to Representative Knaperek's question about funding, Mr. Sandi told the
Committee that the HFA's annual budget was approximately $300,000 per year and that
revenues to the Authority were generated through bond financing activities. He stated
that when the HFA approved bonds, applicants are paying one basis point, which is .01
of one percent of total financing. He remarked that additionally applicants paid 7.5 basis
points which was equal to .075 percent. Mr. Sandi told the Committee that the HFA
brought in between $300,000 to one million dollars per year, a five year cycle with one
million dollars every fifth year. He added that the extra money was used for loans to
other healthcare facilities in underserved parts of the State. Mr. Sandi told the
Committee that the credit rate was predicated on a number of things, the most
prominent being the credit worthiness of the applicant and also on the term and purpose
of t.b.e loan. He remarked that he had seen the interest rates in the range of about four
pement up to about seven percent. '
Representative Knaperek asked the amount of savings in interest rates there was for
people who used the HFA services. Mr. Sandi responded that historically, the industry
used a figure of 15 percent savings going to tax exempt financing versus taxable
financing. He stated that today, when interest rates are lower, that 15 percent figure
would be closer to 10 or 11 percent.
In response to Representative Quelland, Mr. Sandi stated that the title holder on any
property in which the HFA loaned money is going to be that non-profit corporation. He
remarked that the HFA had liens on record for every loan they do. Mr. Sandi explained
that the bond financing has specific guidelines and rules the HFA must follow in the
event of a default.
In response to Senator Leff, Mr. Sandi told the Committee that HFA hired a lobbyist
solely from lack of experience with legislative scenarios and to help the organization
navigate through the process.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Health
Facilities Authority Board for ten years. By voice vote, the motion
CARRIED.
Presentation by the Medical Radiologic Technology Board of Examiners
Aubrey Godwin, Director, Radiation Regulatory Agency, told the Committee that the
Medical Radiologic Techno!ogy Board of Examiners (MRTBE) was created in 1977 by
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legislation due to the large number of unqualified technicians in the State. He stated that
the role of MRTBE was to make sure that technicians or people applying ionizing
radiation to a human being had been properly trained. He remarked that the type of
technologist observed by MRTBE were X-ray, therapy, nuclear medicine and
mammography technologists. Mr. Godwin pointed out that nuclear medicine technology
had been added recently to MRTBE's certification program. He stated that MRTBE
presently had approximately 9,000 certificate holders, some of whom hold dual
certification. Mr. Godwin pointed out that most of the MRTBE cases dealing with
disciplinary matters were related to failure to pay dues or questionable certifications
since their last sunset review.
In response to Senator Allen, Mr. Godwin explained that drug treatment was made
available through MRTBE for certified technicians who may need it and failure to
successfully complete these proceedings would result in termination of certification.
In response to Senator Cannell, Mr. Godwin said that most of the drug related issues
with technicians took place in larger institutions such as hospitals as opposed to private
physician offices. He stated that if the institution where a troubled technician worked
had a drug treatment program, MRTBE would direct the technician to utilize that
program and 'If not, tt1e technician would attend an independent drug program paid for
by the technician.
In response to Senator Arzberger, Mr. Godwin remarked that due to the different State
requirements for technician certification, out of town applicants must be certified in
Arizona before working in this State.
In response to Representative Knaperek, Mr. Godwin told the Committee that there
were both nationally certified and non-nationally certified radiological technician schools
in Arizona. He stated that the vacancy on MRTBE had been available for less than one
year.
In response to Representative Murphy, Mr. Godwin told the Committee that he looked
forward to finding a citizen to fill the vacancy on the MRTBE.
In response to Representative Knaperek, Mr. Godwin remarked that due to the shortage
of technicians in the State, Arizona has experienced an influx of out of State
technicians.
In response to Senator Allen, John Gray, Program Manager, MRTBE, informed the
Committee that a high school graduate could enter into the field of radiological
technology either through community college or privately funded programs. He added
that private school training took two years or less.
In response to Senator Leff, Mr. Godwin stated that there was a continuing education
requirement in place for the field of radiological technology due to changing technology.
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Public Testimony
Jerry High, Arizona State Society of Radiologic Technologists, told the Committee
that out of concern for public safety, he was glad that certification was required before
becoming a technician.
In response to Senator Left, Mr. Hyde said that passing the "Registry," a test sponsored
by the American Association of Radiologic Technology (AART) was very difficult, yet
allowed him to be nationally certified.
In response to Senator Left, Mr. Godwin told the Committee that radiologic
technologists were certified professionals, not licensed professionals.
Stephen Sapareto, Director of Medical Physics, Banner Good Samaritan Hospital,
stated that he was the boss of the technologists at his facility and expressed the
importance of technologists to be certified. He pointed out that another group certified
by MRTBE were radiologic therapists, who administered ongoing care such as
chemotherapy, and that it was especially important for these therapists to be certified.
In lesponse to Senator Left, Mr. Safereto explained that radiologic technologists .and
therapists had a chief technologist or therapist supervising them, followed by a chain of
command that ultimately led to a physician at his facility.
Jeff Siupik, Director of Radiation Services, MRTBE told ~he Committee that being a
director of technologists, he is concerned about the shortage of technologists in the
State due to strict standards by the MRTBE on non-local technologist operating
machinery in a crisis situation.
Senator Left opined that two weeks, the time it takes for MRTBE to certify a non-local
technician, was not a long period of time.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue" the Medical
Radiologic Technology Board of Examiners for ten years. The motion
CARRIED by voice vote.
Presentation by the Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers
Allen Imig, Executive Director, Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers (BENCIAIALFM), informed
the Committee that the Board was created in 1975 to protect the public's health and
welfare by regulating and licensing nursing care institution administrators. He stated that
in 1990, the board statutes were amended to add the responsibility of certifying and
regulating adult home care managers and renamed in 1998 to Assisted Living Facility
Managers. The mission of the Board was to protect the health, welfare and safety of its
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citizens, to seek and institute the use of services of nursing care institution
administrators and assisted living facility managers. Mr. Imig said that the Board's
procedures helped ensure quality and competency standards were met by
administrators and managers. In addition, the Board approves continuing education
courses to make sure quality and useful education is being taught. He explained that
since June of 2005, the Board had undergone an "extreme makeover" with virtually all
new members being appointed. This reduced the back log of uninvestigated complaints
significantly. Mr. Imig told the Committee that the Board had reduced their staff from five
to three, leaving an executive director, investigator and a licensing coordinator. He
encouraged the Committee to continue the BENCIAIALFM.
In response to Senator Allen, Mr. Imig said that the Board consisted of five managers,
two public members and the remaining members were administrators.
Senator Allen opined that home care nursing staff deserved better pay.
In response to Senator Waring, Mr. Imig stated that the changes made to the Board has
helped, but not solved its financial problems.
In response to Senator Arzberger, Mr. Imig said that his Board investigated complaints
from citizens regarding private care nurses and administrators as well as complaints
filed by the Department of Health Services.
In response to Senator Waring, Mr. Imig told the Committee that the Board's website
contained information regarding decisions on disciplinary action.
In response to Senator Allen, Mr. Imig explained that out of the last renewal period for
managers, 2,000 of 2,500-2,600 renewal notices sent were renewed, causing 578
expired notices to be sent by the Board.
In response to Senator Leff, Mr. Imig opined that his Board received between 60 and 70
complaints a year, mainly not health care related but administrative related.
In response to Senator Waring, Mr. Imig stated that with the current staff, the Board
should catch up on its back log of complaints by January 2006.
In response to Representative Quelland, Mr. Imig remarked that the Board was actively
seeking replacements for the three vacancies on the Board.
Senator Leff suggested that the Committee send a letter to the Governor encouraging
her to appoint the three positions.
In response to Representative Quelland, Mr. Imig opined that he would like to see a five
year continuation be given to the Board.
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Representative Knaperek remarked that time elected to the Board would reflect
concerns with term limits and not reflect faith in Mr. Imig.
Public Testimony
Robert Frechettee, President, Arizona Health Care Association (AHCA), told the
Committee that on behalf of his Board, he would like to offer support in the continuation
of the BENCINALFM. He opined that the efforts implemented by the new staff showed
that the Board was very serious about suggestions and concerns brought forth by the
Legislature.
In response to Senator Waring, Mr. Bruschette stated that the AHCA was seen as the
organization that represented the for profit facilities, containing some non-profit facilities
and representing assisted living communities and independent full service communities.
He said that Assisted liVing Federation represents assisted living centers in homes and
the Arizona Association of Homes for the Aging represents a number of facilities seen
as non-profit businesses.
In r~sponse to Senator Cannell, Mr. Bruschette opined that if fee increases were
nec~sary to fund the continuation of the Board, that it would be supported by AHCA.
Senator Leff stated that if the Committee made a five year recommendation at this
meeting and the audit comes out in December and is changed, the legislation coming
out in January does not have to be the same as the recommendation.
Representative Knaperek told the Committee that Mr. Imig had a good work history as a
Director in other fields.
In response to Representative Knaperek, Beth Kohler, Senate Health Research Analyst,
stated that the first audit of the Board would take place approximately six months after
nomination adding an 18 month follow up audit, only if the requirements and
recommendations made by the report were not met
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners of Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for two years. The motion
FAILED.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for five years pending the
findings of the Auditor General's report due in December of 2005.
The motion CARRIED.
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Presentation by the Board of Homeopathic Medical Examiners
Chris Springer, Executive Director, Homeopathic Board, told the Committee that
she had worked for the Board of Homeopathic Medical Examiners (BHME) since 1999.
She complimented appointments made to the Board by all of the Governors on both the
Democrat and Republican side. She opined that the laws governing the licensing of
homeopathic physicians set forth by the State had been upheld. Ms. Springer stated
that a potential audit could be helpful in improving procedures and welcomed the
process of an impartial audit. She said that the Board currently has 117 licensed
homeopathic physicians.
Senator Leff opined that it was nice to hear Ms. Springer suggest an audit of the Board
and noted that BHME had gone approximately 20 years without an audit.
Senator Allen opined that she would like to see an audit of the BHME as well. She
added that in no way did legislation intend to do away with the homeopathic form of
medicine.
In response to Representative Lopez, Ms. Springer stated that a licensed homeopathic
physician could only continue to practice in one state after receiving disciplinary action
in another state for less than one year, due to the Board's annual. renewal application
required of all homeopathic physicians, which would discover the violation in the other
state. .
In response to Representative Murphy, Ms. Springer said that there was the possibility
of a physician being dishonest about any past disciplinary action, however, there is a
standard penalty in place for such an event.
In response to Senator Waring, Ms. Springer told the Committee that there was not an
easily accessible data base of criminal background checks for physicians and added
that the fee to search names on the federal data base was $3.75 per name.
Senator Leff opined that being dishonest on an application should have strong
consequences for any physician when dealing with the subject matter of past
disciplinary action.
Dr. Charles Schwengel, President of the Homeopathic Medical Licensing Board,
told the Committee that being dishonest on an application was the most egregious of
unprofessional conduct that could happen.
In response to Representative Knaperek, Ms. Springer stated that a physician lying on
the application was discovered once and a letter of concern was issued.
Representative Knaperek opined that there should be a certain amount of consideration
afforded to the applicant on whether the incident was an issue of forgetfulness or
deliberate intent.
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In response to Senator Cannell, Ms. Springer stated that setting aside funds to check
each individual physician's background would be a step in the right direction.
Senator Allen remarked that the concerns stated today could be addressed in the
forthcoming audit.
In response to Representative Quelland, Ms. Springer told the Committee that some
traditional doctors became homeopathic physicians, and then dropped their traditional
medical license.
In response to Representative Quelland's comments on a medical doctor dropping their
license to pursue homeopathy due to decreased chances of medical malpractice
occuring, Dr. Schwengel remarked that he could not comment on the personal reasons
a physician might do this.
In response to Representative Murphy, Ms. Springer stated that the percentag~ of
homeopathic physicians who were previously licensed as medical doctors was very low.
Repfasentative Murptfy told the Committee that some physicians may choose to not
carry medical malpractice insurance to avoid becoming a target for medical malpractice.
Senator Cannell opined that there was a fear with physicians of becoming a target for
medical malpractice by carrying medical malpractice insurance.
In response to SenatorWaring, Ms. Springer stated that BHME kept records indefinitely
of reported complaints against homeopathic physicians. She told the Committee that in
her opinion, the BHME should only keep records for up to five years similar to other
medical boards.
In response to Senator Waring, Ms. Springer remarked that she felt it necessary to keep
records of complaints for longer than five years, only if they were substantiated.
In response to Senator Allen suggesting that more public members should be on the
BHME, Ms. Springer said that additional public members on the Board would be a good
idea.
Public Testimony
Dr. Kathleen Fry, dually licensed by the Arizona Medical Board and Arizona
Homeopathic Medical Board, told the Committee that she had gathered a large
amount of important information pertaining to the BHME that she would like to share
with the Legislature and the Office of the Auditor General. She stated that she had been
committed to the practice of homeopathic and alternative medicine for twenty years in
Scottsdale, Arizona. She remarked that it was not her intent to keep patients from
receiving homeopathic care. Dr. Fry opined that the BHME had been grossly negligent
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in its spiritual, moral and judicial responsibilities to protect the public from unscrupulous
physicians by licensing felons, failing to adequately discipline physicians who had
harmed patients, failing to adequately file complaints against other board members and
by giving licenses to physicians who could not pass a basic oral examination of
homeopathy. She stated that when she was recruited to the BHME in 1994, she was
informed by the Board that her dues were necessary to keep the Board in existence and
to allow her to continue to practice homeopathic medicine. Dr. Fry remarked that the
dues for the Association were $1000 per year in addition to the $500 per year licensing
fee and the $150 dispensing fee. She explained that if a homeopathic physician in
Arizona lost their M.D. license in another state, they could still practice homeopathy
here in Arizona which gives that physician the power to write prescriptions for all
classes of drugs, conduct minor surgery in their office, perform acupuncture and various
other medical techniques. In conclusion, Dr. Fry told the Committee that the
homeopathic license gives the physician a much broader range of modalities that they
can use with much less scrutiny and training.
In response to Senator Waring, Dr. Fry stated that in theory, physicians who had marks
on their records in other states should be rehabilitated in that state before being allowed
a license in Arizona, but that had not always been the case.
In response to Representative Knaperek, Dr. Fry remarked that transcripts from board
meetings that she had obtained from Ms. Springer, were public record.
In response to Senator Leff, Dr. Fry explained that a device called a sputnik originated
in Russia and is swallowed by a patient and designed to kill parasites by radiation. She
told the committee that a physician sold the device to a patient in Florida over the
phone, and that upon taking this device orally, the patient developed a bowel
obstruction resulting in the removal of several feet of her intestine. She added that the
said physician, being one of the originators of the BHME, only received a letter of
concern and an apology by the Board for placing that letter in the physicians file.
In response to Senator Waring, Dr. Springer told the Committee that she disagreed with
Ms. Fry's perception of the Board.
Dr. Todd Rowe, Homeopathic and Integrative Medical Physician, Desert Institute
of Classical Homeopathy, dually licensed, told the Committee that he had been
practicing homeopathic medicine for over twenty years. He urged the Committee to
continue the BHME. He remarked that after attending several meetings over the years
of the BHME, he had found most of what Dr. Fry said to be untrue.
In response to Senator Cannell, Dr. Rowe stated that the number of out-of-state
homeopathic physicians licensed in Arizona was very small. He explained that Arizona
was one of only three states who had homeopathy boards and that this was another
reason for an increase in out-of-state applicants in this State.
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In response to Senator Leff, Dr. Rowe said that his homeopathy school had a 1,000
hour program for homeopathy, with plans on expanding that program to 4,000 hours
within the next few years.
In response to Senator Leff, Dr. Rowe stated that the qualifications for a license for
homeopathy consisted of either 40 hours of class of homeopathy, in addition to 300
hours of alternative medicine, or 90 hours of class for homeopathy. He opined that this
met the minimum requirements to become a homeopathic physician and commented on
the fact that some applicants were already licensed.medical doctors.
Lee Bakunin, practicing attorney in Arizona for 36 years, representing self, told the
committee that he had spent the last eleven years of his life studying homeopathy. He
explained that after the required 90 hours, there was no continuing education required
to continue practicing homeopathy. Mr. Bakunin said that the Auditor General may
come across the problem of incomplete records of past BHME meetings.
In response to Representative Quelland, Mr. Bakunin said that he currently had studied
about 2,000 hours of homeopathy.
Gla,~ys Conroy, patient of homeopathy, representing self stated that homeopathy
had saved her life. She told the Committee that standard medication caused her great
danger.
Clifford Heinrich, practicing family physician for alternative medicines, opined that
no alternative medical board should be able to have jurisdiction over the spiritual
practice of homeopathy. He added that he had obtained over 1,200 hours of
homeopathy. Dr. Heinrich told the Committee that he had a petition with 200 signatures
recognizing homeopathy as a spiritual practice. He stated that he had an additional
petition to request the Legislature audit the BHME for "reasons previously addressed in
themeeting.""
In response to Senator Allen, Dr. Heinrich opined that· homeopathy was being
misrepresented by the BHME from its original spiritual foundation, causing the public to
believe they were receiving homeopathic care when in fact, they were not.
In response to Representative Knaperek question about the spiritual aspect of
homeopathy, Dr. Heinrich explained that a nonmaterial substance was one that had
been diluted to a point where the original property is no longer there, leaving only the
essence of that object.
In response to Representative Murphy, Dr. Heinrich told the Committee that he wanted
the separation between homeopathy and alternative medicines distinguished by the
State.
Amanya Jacobs, Director of Evolution of Self/Soul School Homeopathy, remarked
that she was deeply committed to making homeopathy available to all citizens in the
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State. She said that the Board regulated activities that it deemed homeopathy which
were totally unrelated to that area of medicine. Ms. Jacobs stated that she was in favor
of an audit of the BHME.
Linda Heming, Arizona Homeopathic and Integrative Medical Association, told the
committee that western medicine could not help her and homeopathy saved her life.
Senator Leff remarked that the open meeting law stated that recordings and minutes
must be kept by the open body and must be accurate and open for inspection three
days after the meeting, with no language about whether or not they could be destroyed
at any time period.
Russell Olinsky, patient of homeopathy, spoke in favor of the BHME.
Cynthia MacLuskie, patient of homeopathy, told the Committee that all homeopathy
medicines were not available at health food stores and that prescriptions were the only
way to obtain some of these medicines.
Lisa Platt, Arizona Homeopathic and Integrative Medical Association, speaking on
behalf of the BHME, remarked that BHME was not recruiting felons. She stated that a
number of patients had told her how homeopathy had saved their lives.
Senator Allen moved that the Senate Health and House Health
Committee of Reference recommend that the Board of Homeopathic
Medical Examiners continue for two years, adding the request for an
audit addressing the concerns covered in today's committee.
Representative Quelland explained his vote. He said that although he did not have an
educational background in homeopathy, the homeopathic physicians had a certain
amount of disagreement and confusion among themselves. He reminded the
Committee that this was just a recommendation and that someone was going to create
a bill and that bill would be voted on, making today's vote not a guarantee that the
Board will continue, and he voted "aye."
Senator Cannell explained his vote. He said that although he advocated homeopathy
and the continuation of the Board, that the BHME had suffered a "major black eye"
today. He opined that the director and the president of the boards had not changed their
attitudes and that they should consider their Board a precious commodity by not diluting
their group of good physicians with out of state applicants with questionable credentials
and he voted "aye."
Senator Leff explained her vote. She requested the Auditor General to do both a
financial and performance audit. She remarked that the people who came forward today
against the Board should feel free to do so without retaliation and she voted "aye."
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Senator Waring explained his vote. He said that he was very frustrated with the Board,
and that he would be the first to vote "no" on a bill in the following session if changes
weren't made, but since today's vote was merely a recommendation, he would vote
"aye."
Representative Murphy explained his vote. He said that he shared many of the
concerns voiced by the Committee members today and looked forward to hearing what
the Auditor General had to say and he voted "aye."
The motion CARRIED by a roll call vote of 9-0-1 (Attachment 1).
Representative Murphy RECESSED the meeting at 1:35 p.m. to the sound of the gavel.
Representative Murphy RECONVENED the meeting at 2:30 p.m.
Presentation by the Arizona Midwifery Institute
Marinah Valenzuela Farrell, President of the Arizona Midwifery Institute (AMI),
submitted handouts (Attachment A) and (Attachment B) to the Committee. She told the
CorWmlttee that as midwives, their main concern was for safe outcomes of mothers and
babies. She remarked that midwives chose home birth because they believe that birth is
a natural and safe event in the life of a woman. Ms. Farrell explained that in the 1970's,
midwifery became licensed in the State, yet because of medical liability issues,
midwives had experienced difficulty in consults with physicians and access to items to
assist in home birth. . .
In response to Senator Allen, Ms. Farrell stated that midwife licensing exams were very
tough and that she had received specialized intravenous training in New Mexico through
the local hospital.
In response to Senator Cannell, Ms. Farrell told the Committee that licensing of
midwives was dependent upon number of hours of experience in child birth delivery with
that applicant. She stated that there were also schools available to midwives that
involved intense clinical training. Ms. Farrell said that a surveyor in the Department of
Special Licensure administered a national exam to applicants in which upon passing,
the applicant must then go through an oral board and upon passing this, must complete
a practical exam which is overseen by the surveyor and other midwives. She told the
Committee that midwives were trained in resuscitating babies.
In response to Senator Leff, Ms. Farrell stated that the midwives were requesting that a
physician not be required to sign off on supplies.
Representative Lopez opined that her own personal experience of giving birth to her last
two children at home from midwives was a wonderful experience.
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Representative Quelland informed the Committee that Arizona had 53 licensed
midwives with 22 of them located in Maricopa County and that there were 343 midwife
births in the home in 2004 in the State.
In response to Representative Quelland, Ms. Farrell remarked that none of the 343
reported midwife births reported in 2004 resulted in any problems. She stated that
although medical malpractice and liability insurance was available to midwives, the
majority refused it due to its cost in proportion to their pay. She told the Committee that
the Arizona Health Care Cost Containment System (AHCCCS) discontinued the
payment for midwife delivery two years ago due to midwives not carrying medical
malpractice and liability insurance which could possibly put AHCCCS at risk for such
claims.
Senator Leff stated that midwives dealt mostly with low-risk births and that she would
like to see the issue of AHCCCS discontinuing payment for midwife births examined.
Senator Cannell opined that the Committee should hear from AHCCCS because they
obviously found midwifery funds a financial risk for some legitimate reason.
Ms. Farrell told the Committee that mothers who chose home births mainly did so, not
for financial reasons, but because of belief that the hospital environment was just one
intervention leading to another.
Public Testimony
Rory Hays, Arizona Nurses Association, said that the items asked for by the AMI
were appropriate, if accompanied by more training. She stated that she opposed
expanding prescription privileges for anything requiring a Drug Enforcement Agency
number.
In response to Representative Quelland, Ms. Hays said that certification would be
appropriate for midWives.
Ms. Farrell stated that the only thing midwives were requesting was the power to obtain
items already in their reach through a physician, without that physician's pre-approval
and that the laws were already in place on limitations for uses with these items.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for Arizona's licensed midwives by
allowing procurement, possession, and administration of various
medical devices and medications which will be named in the bill. The
motion was CARRIED by voice vote.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 14
Senator Allen opined that midwifery was a choice to be made by the citizen and she
hoped that fatalities did not occur due to the choice of using such a method.
Presentation by the Arizona Association for Home Care
Suzanne Gilstrap, representing the patients for the Arizona Association for Home
Care (AAHC), stated that AAHC was founded in 1983 with a mission to advance quality
home care as an integral component of the health care delivery system. She told the
Committee that she believed in continuing education for home care providers. She
remarked that AAHC had discussed having a joint workshop with the Physical Therapy
Association (PTA) but never actually initiated these workshops. Ms. Gilstrap requested
that the Committee grant an expansion to allow physical therapy assistants to work
under general supervision of a physical therapist as opposed to direct supervision. She
told the Committee that the AAHC respectfully requested the joint Committee
recommend that physical therapy assistants be allowed to practice in the home health
care setting and only in that setting under the following conditions:
• The supervising physical therapist shall be solely responsible for
evaluating the patient and determining a plan of care.
• The supervising physical therapist shall be available at all times via
telecommunication while the physical therapist assistant is providing
treatment interventions.
• The supervising physical therapist supervises no more than two physical
therapy assistants. .
• The supervising physical therapist shall see the patient and revise the plan
ofcare no less than every 21 days.
• The supervising physical therapist not assign responsibilities to the
physical therapy assistants that in any way allow them to provide
evaluation services for procedures.
• Continuing education requirements should be added to the statute as well.
• The physical therapist would be the one responsible for final evaluation
and discharge of the patient.
In response to Senator Arzberger, Ms. Gilstrap said that proposing a mileage limit would
be a good idea in reference to a physical therapist along with the constant
telecommunication contact. She stated that it was not unusual to recommend that the
practice of home care be extended to other areas outside of the home such as
hospitals.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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Tuesday, November 8, 2005
Page 15
In response to Senator Leff, Ms. Gilstrap remarked that the AAHC was not intending to
mandate what physical therapists do, but to enable legislation that would allow them to
choose.
In response to Representative Murphy, Ms. Gilstrap stated that home care therapist
assistants were well schooled for their job no matter what setting, with the exception of
no clinical experience required of the physical therapist.
In response to Senator Waring, Ms. Gilstrap remarked that in all fields of medicine,
health care providers were experiencing an inability to serve patients.
Representative Lopez opined that an outside organization should not be directing
physical therapists on how to conduct their practice.
In response to Senator Allen, Ms. Gilstrap told the Committee that currently more than
45 states allow general supervision in the home health care setting and that the only
two states that do not allow it are Pennsylvania and Arizona.
Public Testimony
Karen Jeselun, President of the Arizona Association for Home Care, stated that
even if there were no home care physical therapist available at the time, a patient could.
still be released from the hospital even though they required home care to continue
recovery. Ms. Jeselun compared the relationship between a physical therapist and a
physical therapist assistant to that of a registered nurse and a licensed practical nurse.
She told the Committee that all of their home care providers go through an interview
process, a mandatory criminal background check and participate in orientation often
with preceptors.
In response to Representative Knaperek, Ms. Jeselun stated that Medicare currently
paid home health agencies on an episode basis, meaning for every 60 days of time that
patient is in the care of a home health provider, the home care provider gets a lump
sum. She opined that she was hoping to serve more patients with no increase in cost.
Susie Stevens, representing the Arizona Physical Therapy Association (AZPTA),
informed the Committee that the definitions of general supervision and direct
supervision needed to be reviewed. She stated that she was there in opposition to the
sunrise request.
Heidi Herbst Paakkonen, Executive Director of the Arizona Board of Physical
Therapy (ABPT), told the Committee that the ABPT regulates about 3,200 physical
therapists and 434 physical therapist assistants. She said that due to lack of detailed
information at this time, she would encourage the Board to oppose the Sunrise
Application of the AAHC.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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Tuesday, November 8, 2005
Page 16
In response to Representative Knaperek, Ms. Paakkonen remarked that there were
exactly 3,268 licensed in the State but not all of them worked in Arizona. She told the
Committee that approximately 2,800 physical therapists listed Arizona addresses. She
stated that there were 434 physical therapy assistants and that approximately 396
reside in Arizona and that it was ABPT's estimate that 350 of them were currently
working in the field of physical therapy.
In response to Representative Quelland, Ms. Paakkonen stated that the ABPT was
required by statute to have three physical therapists and two public members, but no
physical therapist assistants.
In response to Senator Leff, Ms. Paakkonen told the Committee that the ABPT does
and has disciplined physical therapist assistants.
Bob Direnfeld, President of the Arizona Physical Therapy Association (AZPTA),
remarked that his organization was the only one in the State representing physical
therapists. He told the Committee that his association opposed the idea of general
supervision. Mr. Direnfeld said that patients were getting discharged from the hospital
too early in most cases compared to years ago, which cause a greater need for these
home care physicians. He remarked that a therapist was ultimately responsible for
anything the physical therapy assistant does which puts the physical therapist's license
on the line.
In response to Representative Murphy, Mr. Direnfeld opined that passing legislation
supporting general care could potentially decrease an even larger amount of physical
therapists.
In response to Senator Cannell, Mr. Direnfeld stated that he was not sure that there was
a shortage in home health care providers. He also remarked that setting a parameter or
definition of a home care patient, would cut down on the patient load.
Representative Knaperek opined that physical therapist assistants should have more of
a vote on the Board.
Peter Zawicki, in favor of the sunrise recommendation, told the Committee that
physical therapists and physical therapist assistants were trained at community colleges
and technical schools across the country. He opined that it was critical that there be
communication between the physical therapist and the physical therapist assistant in all
patient care.
In response to Senator Cannell, Mr. Zawicki stated that physical therapist assistants
were under direct supervision during the education process.
In response to Representative Murphy, Mr. Zawicki remarked that to be able to perform
in public health care, it would be helpful if a physical therapist assistant had a certain
amount or certain type of training.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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Tuesday, November 8, 2005
Page 17
Senator Leff opined that home health patients are the most vulnerable patients and she
felt uncomfortable "experimenting" with the care of those patients.
Kerry Halcomb, Physical Therapy on Wheels, representing AAHC, opined that he
did not believe that a physical therapist could adequately supervise a physical therapist
assistant.
Gayle Haas, physical therapist, representing AAHC, remarked that a physical
therapist and a physical therapist assistant can work together for years and develop a
relationship which allowed for better understanding and communication skills with one
another.
Deborah Bornmann, physical therapist, stated that she did not feel represented by
her own board. She opined that it was great for an outside organization to try to help
physical therapists.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for licensed. physical therapist
assistants by allowing home health visits under the general
. supervision of licensed physical therapists. The motion was
CARRIED by voice vote.
Senator Waring stated that although he was unhappy with what he had heard
today, he hoped discussions were started to improve the situation.
Representative Knaperek remarked that she hoped they could work out their
differences for the benefit of the State.
Senator Arzberger opined that changes do need to be made and issues need to
be addressed. .
Representative Murphy stated that hopefully, this would get people back into
discussions.
There being no further business, the meeting was adjourned at 5:12 p.m.
Respectfully submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115.)
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8,2005
Page 18
Senate Health and House of Representatives Health Committee
of Reference
ARIZONA STATE LEGISLATURE
FORTY-FIFTH LEGISLATURE- ROLL CALL VOTE
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Rep. Bradley
Rep. Lopez
Rep. Quelland
Senator Cannell
Senator Arzberger
Senator Allen
Senator Left
Senator Waring, CoChair
Rep. Murphy, CoChair
Rep. Knaperek I ... . :i
Committee Secretary jf1'P'f?' =wf:-.N~ Date \ I-O~ '""'dOD)"
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November 8, 2005