The4th meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, October 15, 2008, at 1:00 PM, in Room 131 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:10 PM, and the secretary called the roll.
Members:Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, Denise Harper Angel, Alice Forgy Kerr, Joey Pendleton, Dick Roeding, Dan Seum, Katie Stine, and Johnny Ray Turner; Representatives Scott W. Brinkman, James R. Comer Jr., Robert R. Damron, Joni L. Jenkins, Mary Lou Marzian, Darryl T. Owens, Ruth Ann Palumbo, David Watkins, and Addia Wuchner.
Guests: Alex Blevins, Executive Director, Kentucky CASA; Judge Elise Givhan Spainhour, Bullitt County Family Court; Judge Sheila Nunley Farris, Henderson County Family Court; Bart Baldwin, President, Children’s Alliance; Pat Wilson, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services; Jill Seyfred, Prevent Child Abuse Kentucky; Christine and Lara Gelding; Tina Radford, Leslie Beam; Rebecca Cecil, Executive Director, Commission for Children with Special Health Care Needs; Peggy Howard, Surgical Technology Director, KCTCS, Owensboro; Dr. Herman Kaebnick, M.D., Vascular Surgeon; Sandra Smith, RN, BSN, Surgery Educator; Kim and Brian Nelson; Bill Doll, Kentucky Medical Association; Guy Delius, Department for Public Health, Cabinet for Health and Family Services; Kim Dees and Sarah Nicholson, Kentucky Hospital Association; Duncan Pitchford, CASA of Kentucky; Paula Pabon, Kentucky Board of Nursing; Thomas H. Pinkstaff, M.D. and Susan Noel, ARNP, University of Kentucky; Don Putnam, PROOF – Oakwood; Troy F. Bell, Administrative Office of the Courts; Eric T. Clark, Kentucky Association of Health Care Facilities; Alice Martin, CASA – Franklin County; and Shane O’Donley, Office of Certificate of Need, Cabinet for Health and Family Services.
LRC Staff: DeeAnn Mansfield, CSA; Mike Bossick, Miriam Fordham, Ben Payne, Gina Rigsby, and Jonathan Scott.
A motion to approve the minutes of the September 5, 2008 meeting was made by Senator Pendleton, seconded by Representative Watkins, and approved by voice vote.
The following administrative regulations were referred to the committee for consideration: 201 KAR 20:410 – establishes which records may be expunged by the Kentucky Board of Nursing and the procedure for expungement; 201 KAR 23:015 – establishes the requirements for the granting of temporary permission to engage in the practice of social work; 201 KAR 23:070- establishes the educational institutions approved by the board, the definitions relating to supervision, the content of a Contract for Clinical Social Work Supervision and the requirements for experience under supervision; 201 KAR 35:020 – establishes an initial certification fee and renewal fee by the Board of Certification of Alcohol and Drug Counselors; 201 KAR 35:040 – establishes the requirements for continuing education for certified alcohol and drug counselors and prescribes methods and standards for the accreditation of continuing education courses; 201 KAR 35:050 – identifies the areas of study that will satisfy the requirement for certification as an alcohol and drug counselor; 201 KAR 35:060 – establishes procedures for the filing, evaluation, and disposition of administrative complaints by the Board of Certification of Alcohol and Drug Counselors; 201 KAR 35:070 – establishes the standards for the accumulation of the required supervised work experience with a certified alcohol and drug counselor who has at least two years of postcertification experience; 900 KAR 6:050 & E – establishes the requirements necessary for the orderly administration of the Certificate of Need Program; 902 KAR 45:150 – establishes uniform standards for schools and includes sanitary standards for operation, inspections, and enforcement of procedures necessary to insure a safe and sanitary environment; and 922 KAR 1:360 & E – establishes (a) five levels of care based upon the needs of a child for whom the cabinet has legal responsibility; (b) a payment rate for each level; (c) gatekeeper responsibilities; (d) provider requirements; (e) procedures for classification at the appropriate level of care; and (f) procedures for determination of components of the model program cost analysis.
Senator Stine, Co-Chair, Families and Children Subcommittee, reported the subcommittee met that morning and heard a presentation concerning the condition of apraxia. The subcommittee listened to a presentation from the Kentucky Autism Training Center by Rebecca Grau and the STAR Autism Treatment Services by Dr. Joseph Hersh. Rebecca Cecil, Executive Director, gave an update on the Commission for Children with Special Health Care Needs. A presentation on Preventing Childhood Infectious Diseases was given by Kraig E. Humbaugh, M.D., M.P.H., State Epidemiologist, Director, Division of Epidemiology and Health Planning, Department for Public Health, Cabinet for Health and Family Services.
Representative Marzian, Co-Chair, Health Issues Subcommittee, reported the subcommittee met that morning and heard a presentation on the behavioral health and criminal justice grant program by Donna Hillman, Director, Division of Mental Health and Substance Abuse, Department for Mental Health, Developmental Disabilities and Addiction Services, Cabinet for Health and Family Services, Rita Ruggles, Project Director, Division of Mental Health and Substance Abuse, Department for Mental Health, Developmental Disabilities and Addiction Services, Cabinet for Health and Family Services, and the Honorable Karen Thomas, Chief District Judge, Campbell County. The subcommittee also had an update on the newly established Office of Minority Health within the Cabinet for Health and Family Services from Dr. Ruth Ann Shepherd, Division Director, and Joy Hoskins, Assistant Division Director, Division of Maternal and Child Health, Department for Public Health, Cabinet for Health and Family Services.
An update on the missions and goals of Kentucky CASA (Court Appointed Special Advocate) was given by Alex Blevins, Executive Director, CASA of Kentucky, Judge Elise Givhan Spainhour, Bullitt County Family Court, an Judge Sheila Nunley Farris, Henderson County Family Court. Judge Farris explained that there is a difference between a CASA and a Guardian Ad Litem (GAL). A judge appoints a CASA for the child, who then becomes the advocate or voice of that child for the duration of the case, no matter how long it takes. A GAL gets the cases back on the docket when necessary. Judge Spainhour stated that a CASA helps her not to offend the child and gives her follow-up reports about a child. She said that there is a waiting list of children in need of a CASA volunteer. The CASA volunteers go through a vigorous screening process and also work with social workers who manage a child’s case. The CASA is there for one reason and one reason only, and that is to stand up for the child. The CASA only helps one child at a time and is bound by confidentiality rules. Reunification of the family is the most important thing for the child unless it would be detrimental for the child. A CASA makes sure a case stays on track, and they report progress to the judge.
Mr. Blevins said that the mission of the Kentucky CASA is to present a statewide voice for abused and neglected children and enhance the growth and support of existing CASA programs throughout the state. CASA volunteers serve as a powerful voice for abused and neglected children, one child at a time. There are a total of 21 CASA programs in the Commonwealth. Approximately 7,500 children are in out-of-home care, and every day judges decide the futures of the children in a system that is often too understaffed and overburdened to focus adequately on the needs of each child. Without help, these children are at high risk for homelessness, unemployment, incarceration, and drug and alcohol abuse as adults. CASA volunteers visit the child regularly and provide a consistent presence in his or her life, fully research the child’s history and present situation, file court reports and appear before the judge to advocate for the best interests of a child, and work with others to make sure the child’s needs are being met.
Cases with a CASA volunteer will receive: 1) in-depth review and monitoring of the child’s educational needs; 2) in-depth review and monitoring of the child’s health needs; 3) individual advocacy by one volunteer per case; 4) advocacy for a safe, permanent home for each child. Volunteers are required to finish their cases and seldom does a child switch a CASA. Children with a CASA volunteer, when compared to children in like circumstances without a CASA volunteer, will spend significantly less time in foster care, have fewer disruptions in placement, and have fewer numbers of placements. Currently only Kentucky and West Virginia receive no state dollars for CASA.
Representative Owens asked if the children who have a CASA also have a social worker. Judge Spainhour stated that because social workers have a large caseload, they utilize the help of a CASA. While a social worker may carry 20-25 cases, a CASA takes care of only one child at a time. She stated that not all of the 120 counties have CASA. Judge Farris said that if there are no prior offenses in the child’s home, a judge may contact a CASA while the social worker tries to take care of the child’s physical needs. A CASA will take care of obtaining the child’s legal needs. Mr. Pitchford stated that CASA works as a team member with the Department for Community Based Services.
Senator Denton asked if a CASA would be interested in becoming supervised visitation supervisors. Mr. Blevins stated that CASA standards do not allow a CASA to be the only person at a supervised visit. Senator Denton stated that CASA volunteers would be good supervisors.
Representative Wuchner asked about CASA funding. Mr. Blevins stated that all CASA programs are funded by private non-profit funds. He stated that approximately $3.25 million was raised by grants, fundraisers, and community partners. He said that $1 million was requested from the General Assembly, but the request did not make it into the final budget. It takes $55,000 per year for one CASA program. Title IV-E provides funds for reimbursement of training of CASAs, but Kentucky is ineligible. Representative Wuchner asked about the needs in Kentucky. Mr. Blevins stated that there are approximately 2,116 CASA cases in 42 counties. The CASA programs need approximately $1.5 million in addition to funds raised by grants, fundraisers, and community partners.
A presentation on the challenges of foster care in Kentucky was given by Pat Wilson, Commissioner, Department for Community Based Services, Cabinet for Health and Family Services, Bart Baldwin, President, Children’s Alliance, and Jill Seyfred, Prevent Child Abuse Kentucky. Ms. Seyfred and Mr. Baldwin stated that Prevent Child Abuse Kentucky, the DCBS, and the Children’s Alliance all stand united about the challenges of foster care and seeking solutions. Commissioner Wilson stated that foster care is meant to be a temporary solution. Safety of the child is the main priority, and it is important for the child to have a permanent placement as soon as possible. The department tries to place the child with a family member if at all possible. Approximately 74% of the children are returned to the family. The longer a child stays in foster care, the more chances they will be in placed in several foster homes. Commissioner Wilson stated that approximately 70% of the children do not move in the first month of placement. Approximately 45% of children will stay in the same foster care home within a 12-month period, and 20% with a 24-month period.
Commissioner Wilson stated that there has been an increase in the number of infants coming into the foster care system. The department has been awarded a 5-year, $2 million grant to work on diligent recruitment of foster parents. There are approximately 500 children in foster care that are aggressive, low functioning, have sexual issues and/or have substance abuse problems who are difficult to handle. She stated that placing children in foster care is a statewide, not just in a few geographical areas. The department tries to do what is in the best interest of the child, so approximately 90% of children with sibling(s) are maintained in the same foster home whenever possible. It is very important to keep children together. There are approximately 7,100 children in the foster care system. She said that being in foster care should not have to hinder a child from becoming the best person they can be.
Representative Owens asked about the difference between out-of-home care and kinship care. Commissioner Wilson stated that there are approximately 9,000 children in kinship care. The children in kinship care are not in the custody of the cabinet and guardians are paid from TANF funds. The difference in out-of-home care and kinship care payments is several hundred dollars a month. Representative Owens stated that foster care has different restrictions than kinship care, therefore, kinship care would seem to be a better option if possible.
Representative Watkins asked about the age children leave foster care. Commissioner Wilson stated age 18 unless a child wants an extension because they are still in school. Representative Watkins asked how DCBS handles low functioning children who age out of foster care. Commissioner Wilson stated they remain with DCBS in a different capacity.
A presentation on apraxia was given by Christine Gelding, parent of Lara, a child with apraxia, and Leslie Bean and Tin Radford, family members of Lara. Ms. Beam stated that apraxia is a developmental disorder where a child cannot pronounce words. She was additional speech therapy available. Ms. Radford stated these children belong in the least restrictive environment. She said that some children with speech and communication problems could be diagnosed with apraxia. Each child should have their needs met. Ms. Gelding stated that many parents do not have family support systems. She stated that her daughter needs intense therapy that is not available at this time.
An update on the Commission for Children with Special Health Care Needs (CCSHCN) was given by Rebecca Cecil, Executive Director. Ms. Cecil stated that since 1924, the commission has provided care for children with physical disabilities. There are thirteen regional offices statewide where staff help get care for the children’s needs. A child can receive services if the child is a resident of Kentucky, younger than 21, has a medical condition that usually responds to treatment and is covered by the program, and meets financial guidelines. Patients remain eligible until they reach the age of 21, have gained maximum benefit from treatment, choose to obtain services in another setting, or they no longer comply with a treatment plan or program guidelines. In the Medically Fragile Foster Care Program, one of the licensed registered nurses serves as a consultant to foster parents and the assigned social service worker of any child determined to be medically fragile. Children born in Kentucky have their hearing tested before going home from the hospital. The staff in the Early Hearing Detection & Intervention (EHDI) program can help find services for more testing and resources if a child has a hearing loss. The Foster Care Support Program has a CCSHCN nurse consults in each of the nine DCBS service regions statewide. The nurse consultants are available to all social service workers at any time for matters concerning children in or at risk of out-of-home placement, not just those determined to be medically fragile.
Ms. Cecil stated that in collaboration with the University of Kentucky, CCSHCN maintains a primary pediatric care clinic staffed by professionals familiar with the unique culture of foster care. An array of assessment and care provision/coordination services are available to children in the welfare system. Transition planning and parent consultants help children and families plan and prepare for changes as the children grow.
A presentation on proposed legislation of the Kentucky State Assembly of Surgical Technologists was given by Peggy Howard, Surgical Technology Director, Kentucky Community and Technical College System (KCTCS), Owensboro, Herman Kaebnick, M.D., Vascular Surgeon, Sandra Smith, RN, BSN, Surgery Educator. Ms. Howard stated that the legislation has two objectives: 1) improve patient safety by ensuring all surgical technologists employed in Kentucky healthcare facilities in the future have demonstrated and documented competency as entry-level practitioners, and 2) increase the professionalism and regard for Certified Surgical Technologists amongst their peers. She stated that the KCTCS currently has nine statewide accredited surgical technology programs providing associate degree and diploma education. The programs include basic courses to prepare the student, followed by eleven months of intensive classroom and clinical study. Students will successfully complete 13 to 22 general education credits coupled with 34 additional college credit hours in surgical technology studies. She said that surgical technology practice has a vast potential to impact patient care negatively, and therefore, requires formal training in anatomy, physiology, and surgical procedures that cannot be readily obtained with basic on-the-job training.
The legislation: 1) creates a route-of-entry to the profession of surgical technology after a date certain in the future; 2) creates a hospital credentialing rule via legislation that requires that hospitals hire Certified Surgical Technologists to serve in surgical technologist positions in the operating room; 3) defines the practice of surgical technology; and 4) grandfathers existing practitioners to avoid a shortage of available surgical technologists for surgical patients in any state. The legislation will not: 1) create a shortage of surgical technologists; 2) put existing surgical technologists out of work; 3) force existing surgical technologists to return to school; and 4) impinge on the right of any other duly licensed or credentialed professional in the state to practice.
Dr. Kaebnick stated that he is in favor of the legislation. Surgical technologists are a part of the surgical team, but are the only ones not certified. The main thing is have quality patient care. Ms. Smith stated that she supports the legislation because it would benefit patients by having highly trained people in the operating room.
Senator Denton asked if the legislation mandated hospitals had to use certified surgical technologists. Ms. Smith said there are credentialing schools available statewide. Senator Denton asked if it would be satisfactory if there was voluntary certification. Ms. Smith stated that this is already being done. The main goal is quality patient care. Senator Denton asked why it is necessary to study anatomy and physiology. Ms. Smith said that surgical technologists have to anticipate what tools the surgeon need and are also required to do retraction.
Senator Roeding asked who opposed the legislation, and they said they did not know. Ms. Smith stated that they are advocates for patients’ safe care in the hospital and operating room. Senator Roeding asked for a copy of the bill, and Mr. Nelson stated that a copy would be provided to the committee members as soon as it has been finalized.
Sarah Nicholson and Kim Dees of the Kentucky Hospital Association testified in opposition to the legislation. Ms. Nicholson stated that the Kentucky Hospital Association is in the process of surveying members in 126 hospitals statewide about the legislation. She said that surgical technicians are not available in all rural areas. There are only two states that mandate technicians have to be certified. Ms. Dees stated that the association would support the legislation if it is done in a safe fashion. She said that the hospitals establish and maintain competency of all employees on an annual basis. There are no current studies that state not having certified technicians was detrimental to patient safety. Hospitals need to be able to maintain flexibility when staffing surgical suites. The association supports education and voluntary credentialing, but hospitals should not have to have mandatory certification.
Senator Buford asked if there were enough qualified surgical technicians, and Ms. Dees said yes. He asked about the number of technicians are needed. Ms. Dees said there is no documentation that verifies a difference between certified and non-certified technicians. Senator Buford asked if the association had conducted a survey about the difference, and Ms. Dee stated not yet.
Senator Denton asked if certification of technicians would preclude non-certified technicians from being able to be in the operating room because it would only be in the scope of practice for certified technicians. Ms. Dees stated that most hospitals do use certified personnel over non-certified personnel. Senator Denton asked if facilities in Jefferson County only used certified technicians. Ms. Dees stated that hospitals are trying to hire from accredited programs because the technicians already have the necessary training. Senator Denton asked if any lawsuits had been filed as a result of non-trained technicians. Ms. Nicholson stated that she was not aware of any that have been filed. Ms. Dees asked why we would want two standards of care, urban or rural, because every patient gets the same quality of care. Senator Denton asked about the statewide shortage of surgical technicians Ms. Howard stated that surgery technology will continue to have openings. There is an 80% employability rate after graduation. Senator Denton asked about the cost. Ms. Howard stated the cost is $121 per credited hour times 35 plus the cost of perquisite classes.
Senator Harper Angel asked if certified technicians want higher pay. Ms. Howard stated that her hospital has a surgical level where when you finish all the necessary training you get a raise.
There being no further business, the meeting was adjourned at 3:26.