of the

ASSEMBLY Committee on Health and Human Services


Seventy-Second Session

May 5, 2003



The Committee on Health and Human Serviceswas called to order at 1:36 p.m., on Monday, May 5, 2003.  Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada, and, via simultaneous videoconference, in Room 4401 of the Grant Sawyer State Office Building, Las Vegas, Nevada.  Exhibit A is the Agenda.  Exhibit B is the Guest List.  All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.


Note:  These minutes are compiled in the modified verbatim style.  Bracketed material indicates language used to clarify and further describe testimony.  Actions of the Committee are presented in the traditional legislative style.





Mrs. Ellen Koivisto, Chairwoman

Ms. Kathy McClain, Vice Chairwoman

Mrs. Sharron Angle

Mr. Joe Hardy

Mr. William Horne

Ms. Sheila Leslie

Mr. Garn Mabey

Ms. Peggy Pierce

Ms. Valerie Weber




Mr. Wendell P. Williams (excused)




Senator Valerie Wiener, Clark County Senatorial District No. 3



Marla McDade Williams, Committee Policy Analyst

Terry Horgan, Committee Secretary




Judith M. Wright, Chief, Family Health Services Bureau, Health Division, Department of Human Resources

Helen Foley, representing the Clark County Health District

Tim Crowley, representing the Nevada Resort Association

Van Hefner, President/CEO, Nevada Restaurant Association; President/CEO, Nevada Hotel and Lodging Association

Kim Neiman, RN, MPH, CIC, Diabetes Prevention and Control Program, Health Division, Department of Human Resources

Donna Johnson, Director, Northern Nevada Branch of the Arthritis Foundation

Mary Liveratti, Deputy Director, Department of Human Resources

Jon Sasser, representing Washoe Legal Services

Mark Nichols, Executive Director, National Association of Social Workers, Nevada Chapter


Chairwoman Koivisto:

The Committee on Health and Human Services will come to order, please.  [Roll called.]  Mr. Williams is excused today.  Please mark the others present when they arrive and we will start as a subcommittee.



Senate Bill 307 (1st Reprint):  Requires posting of warnings in certain food establishments regarding risk of drinking alcoholic beverages during pregnancy and merges Advisory Subcommittee on Fetal Alcohol Syndrome into Advisory Board on Maternal and Child Health. (BDR 40-6)


Senator Valerie Wiener, Clark County Senatorial District No. 3:

I notice that the agenda has been changed and that S.B. 307 is first on the agenda.  We have a witness who thought it was going to be second so if [the hearing on S.B. 307 is over when he gets here] could we put him on record then?


Chairwoman Koivisto:

We could.  The reason that S.B. 307 is first is because we are teleconferencing because someone down south wanted to testify and we only have the teleconferencing for a given time.


Senator Wiener:

[Introduced herself.]  I’m here today with two of my bills, the first being S.B. 307, which would [serve] two very important purposes.  First, at the request of the Advisory Board on Maternal and Child Health in the Health Division, the bill merges the Advisory Subcommittee On Fetal Alcohol Syndrome into the Advisory Board on Maternal and Child Health.  We have found since this was first passed four years ago that both of these subcommittees are very active and there’s a lot of redundancy between the two.  At the request of the Maternal and Child Health [Advisory Board] I [added] to this bill the merger so they could work on the same kinds of issues.  You’ll notice in the bill that there are some very specific mandates for the merged version that FAS (fetal alcohol syndrome) not be abandoned and that it be addressed in its individual nature.  The FAS subcommittee itself would not need to exist separate and apart from what was pre-existing which was the Maternal and Child Health Advisory Board.


The second portion of S.B. 307 would require the posting of signs in places where alcohol is served by the drink and consumed on the premises that warn of the dangers of drinking during pregnancy.  This is the second time I have brought this particular provision to the Legislature.  In 1999, the Legislature passed a comprehensive bill on fetal alcohol syndrome.  In 2001, I took another look at the bill and decided that this would be a proper and appropriate opportunity to provide education on the effects of fetal alcohol syndrome.  [That bill] would [have required] signs where liquor was sold by the drink.  That bill last session got through the Senate with unanimous support and came to your Committee.  You, as a Committee, offered some minor changes.  However, what can happen [at the end of session] did happen to that bill.  The amendment had physically been lost.  Another copy of the amendment was hand-delivered and the bill did pass your house in the final Floor Session but didn’t get back [to the Senate in time] and died.  It received support from both houses; the timing was just a little off.


S.B. 307 of this session is an effort to approach the sign issue again to post signs where liquor is sold by the drink.  Last session the March of Dimes had offered to print enough signs for statewide distribution.  During the interim they printed [signs] and the Health Division distributed 3,500 [of them] to facilities and establishments that volunteered to take the signs.  As I did in the Senate, I will offer to your Committee and the full Assembly, if the March of Dimes is unable to bear the cost of printing those signs, I will donate between 10,000 and 15,000 signs to meet the requirements of S.B. 307.


When I first started with this issue in 1999, it was estimated that fetal alcohol syndrome imposed an additional cost to society of $1.5 million per child.  The most recent recalculation includes costs to the family, additional health care costs, as well as juvenile and criminal justice costs imposed by fetal alcohol syndrome on that child.  The new price tag is an astronomical $4 million of additional lifetime expenditures per child.  Most of this cost is carried by the taxpayer.  What is essential for us to remember is that we can completely, totally, avoid this multi-million dollar burden.  FAS is 100 percent preventable because it is incurred when mom drinks during pregnancy.  If we could alert mother not to drink during pregnancy we can avoid FAS.


[Senator Wiener, continued]  No one knows which drink triggers it.  Several years ago doctors told their pregnant patients only heavy and frequent drinkers produce FAS in their unborn children.  Four years ago when I brought the original bill on FAS doctors were telling their patients, “You can have a drink once in a while to calm your nerves.”  Today the message is ever so clear:  If you are pregnant, or thinking of being pregnant, do not drink. 


As you’ll see in the preamble to the bill, and this is new information to this version produced by the University of Nevada, Reno, FAS is the major cause of disability in Nevada.  We also know that at least, and this is very conservative number, 1 percent of the population has FAS.  This means that at least 21,000 people in Nevada, 15,000 in Clark County, could have been saved from this preventable, lifelong damage if, during pregnancy, their mothers did not consume alcohol.  Certainly, prevention is what it takes to stop fetal alcohol syndrome.  It would be easy to say it’s the health care professional’s job to educate women about the risks of drinking during pregnancy.  Certainly this is true, in part, because it would presume that all health care professionals are providing this education.  This would presume that all pregnant women are getting appropriate prenatal care.  In the packet that I provided for you (Exhibit C) there’s an article, “Patterns: 15% in Study Drank in Pregnancy,” from the New York Times [dated] January 28, 2003.  Obviously, the message isn’t getting out as well as it needs to.  We need to educate women where they will get the message at the time and place where it will have the most impact.


Evidence of this lack of awareness is also clearly demonstrated in a comprehensive national survey conducted in the late 1990s.  Women representing diverse demographic, psycho-graphic, socioeconomic, educational, and cultural backgrounds participated in the survey.  It was quite comprehensive.  When asked what they thought fetal alcohol syndrome was, nearly universally the response was, “A baby born drunk.”  This response, of course, would presume that at some point the baby would sober up. 


Let me make it very clear for all of us what FAS really is.  Fetal alcohol syndrome is not just an irreversible birth defect.  Fetal alcohol syndrome is brain damage.  A baby born with FAS will not sober up.  A baby born with FAS will not get better.  A baby born with FAS will live forever with the overwhelming and negative consequences of his or her mother’s drinking alcohol during pregnancy.  FAS is a major health care problem; it is also a significant problem in other arenas, including juvenile and criminal justice.  We know that 50-60 percent of our juvenile justice population has fetal alcohol syndrome.  Many of these FAS babies become FAS adults in the criminal justice system.


[Senator Wiener, continued]  FAS cannot be cured, but we can prevent it, and we can start preventing it now.  We, as legislators, have an opportunity to reduce the incidence of FAS with Senate Bill 307.  We can require the posting of signs that alert to the dangers of drinking alcohol during pregnancy at places where consumption by the drink occurs.  We can provide this FAS message to many women who often, for the first time, will learn about this danger when they are in places where they are consuming alcohol by the drink.


Chairwoman Koivisto, members of the Committee, rarely do we have such a profound opportunity to prevent this irreversible kind of health problem.  We can prevent fetal alcohol syndrome.  S.B. 307 will help us take a large leap in this direction by informing moms and moms-to-be about one critical way to prevent their unborn children from incurring an irreversible birth defect.  It is for these reasons that I urge your support for Senate Bill 307.


Chairwoman Koivisto:

Questions from the Committee?


Assemblyman Mabey:

As an obstetrician, I agree 100 percent with what you said.  I’ve seen cases of [FAS] and it’s sad.  Women will come in [during] their first trimester for their first visit and will have consumed a lot of alcohol already and you really don’t know what to tell them.  Their baby may already be affected and it’s too late.  I wish somehow we could get to those women who are even thinking about maybe getting pregnant.  If there’s any chance at all [of getting pregnant], you shouldn’t drink alcohol.  I support this.  I just wondered if somehow we could make that label even stronger.  They don’t even know they’re pregnant.  They’ll get pregnant.  Two weeks later they’ll miss their period but [during that two weeks] they may consume a lot of alcohol.


Senator Wiener:

When I speak to teenagers many of them will say, “Well, I got pregnant at a party and I was drunk, so it’s too late.”  I [tell them that] we don’t know which drink does it, but we do know that once the baby has [FAS], each drink will make it worse.  Even in that trimester when they’ve already been drinkers, each drink makes it worse.  There are five levels of FAS and, because of the level of mental retardation that it produces, the worst level [is] very obvious, but there are four levels that you can’t even detect.  I tell young people it’s not just a birth defect, but brain damage.  It will never get better, but drinking during pregnancy can make it worse.


[Senator Wiener, continued]  In the bill you’ll see some language that drinking during pregnancy can cause birth defects.  That language is there as a reference as to how to develop a message.  What the subcommittee had asked was, “Could you not require statutory language, but give us something to work with so we can rework the language periodically.”  Maybe sometime they could say, because it’s just reference language, “If you’re pregnant or thinking of it, know…” They can play with the language; it’s not statutorily described that it has to be the same message all the time.  [Then] they can refresh people about the damage it causes.  This is one of the few disorders that we know how to prevent.  Four million dollars per child of preventable health care and criminal justice and juvenile justice costs [are] pretty substantial.


Chairwoman Koivisto:

Other questions or comments from the Committee?  [There was no response.]


Judith Wright, Chief, Family Health Services Bureau, Health Division, Department of Human Resources:

[Introduced herself.]  I’m here to provide information on S.B. 307.  As you’ve heard, S.B. 307 requires food establishments where alcohol is sold by the drink for consumption on the premises to post bilingual English and Spanish signs warning that drinking alcoholic beverages during pregnancy can cause birth defects. 


Food establishments are already subject to inspection by health authorities so a mechanism for monitoring compliance is already in place.  The most severe birth defect caused by drinking alcoholic beverages during pregnancy is, as you’ve heard, fetal alcohol syndrome.  With the guidance of the fetal alcohol syndrome Subcommittee of the Maternal and Child Health Advisory Board, the Health Division used $25,000 appropriated in 1999 for a fetal alcohol syndrome public education campaign to prepare signs warning that drinking alcoholic beverages during pregnancy can cause birth defects. 


These signs have tear-offs providing women information on how to obtain substance abuse treatment and prenatal care regardless of ability to pay.  The signs are designed to be either freestanding or mounted on a wall.  Grant funding from the March of Dimes allowed the Division to distribute these signs to approximately 3,500 agencies and businesses, including every drinking establishment in the state.


[Judith Wright, continued]  Whether the warning signs are actually posted remains at the discretion of the business owner.  Under S.B. 307, posting of a warning sign would be required of every food establishment selling alcoholic beverages by the drink for consumption on the premises.  Since 1989, alcoholic beverage containers have been required by federal law to have the Surgeon General’s warning that drinking alcoholic beverages during pregnancy can cause birth defects.  Unfortunately, that warning is small and is entirely absent when alcohol is ordered by the glass.  S.B. 307 ensures that the warning is prominently displayed and large enough to be easily read, appears in Spanish as well as English, and is not eliminated when alcohol is ordered by the glass. 


In addition, S.B. 307 makes it possible for the warning to not be repetitive by authorizing, as has been said, regulations [to be developed] providing for alternative forms of the warning signs.  When NRS (Nevada Revised Statutes) 442 was revised in 1999 to require the establishment of a Fetal Alcohol Syndrome Subcommittee, the Maternal and Child Health Advisory Board already had an established perinatal substance abuse prevention subcommittee to address perinatal abuse of alcohol, tobacco, and other drugs.  S.B. 307 would eliminate the requirement to have a separate fetal alcohol syndrome Subcommittee and thus would eliminate some of the duplication of effort and costs that have been associated with having two subcommittees with overlapping duties.


S.B. 307 also eliminates, by statute, who is to serve on the subcommittee that addresses perinatal substance abuse [and] Fetal Alcohol Syndrome.  This would allow the Maternal and Child Health Advisory Board to appoint to its subcommittee those best qualified and most highly motivated to address perinatal abuse of alcohol, tobacco, and other drugs.  For example, current statute requires that the Fetal Alcohol Syndrome Subcommittee have one member who represents the statewide organization in this state for the prevention of perinatal substance abuse.  However, there is no longer such an organization in this state. 


While S.B. 307 requires [that] food establishments serving alcoholic beverages by the glass for consumption on the premises post a warning sign, the consequences for failure to do so aren’t specified. 


Thank you for the opportunity to comment on S.B. 307 and I brought for you today a packet on it that the Fetal Alcohol Syndrome Subcommittee prepared (Exhibit D).


Chairwoman Koivisto:

Why are we just doing this in eating establishments that serve liquor?  Why aren’t we doing it in all the bars, et cetera, as well?


Senator Wiener:

It’s for those that are licensed where drinks are sold by the glass.  Often those bars and taverns have to have food licenses as well even if they [only] have food, munchies, [et cetera] on the counter.  We looked into bars and taverns as well and they’ve been included in the 10,000-15,000 licenses that are out there. 


Chairwoman Koivisto:

Questions from the Committee?  [There were none.]  We’ll [hear from] the folks in support of this first.


Helen Foley, representing the Clark County Health District:

We wholeheartedly support this legislation.  We worked very closely with Senator Wiener last session and we were sorry that things got lost in the last few days of the session. 


In talking to the members of the Health District who deal in this area, they said that when they go and inspect a restaurant or a bar, they have a checklist of what they look at—the cleanliness, the appropriate temperatures of the different refrigeration devices, et cetera.  [Checking to make sure that the warning sign has been posted] would simply be on that checklist.  The [business] would get the appropriate demerits if it wasn’t [posted].  That’s how the law would be enforced.


I recently adopted a child.  When we were talking about deciding what level of drug or alcohol use by the biological mother adoptive parents would be willing to accept, [the risks] became very clear.  Even though I had worked on this with Senator Wiener, I was still quite surprised to hear that alcohol, over any other drug there is, can have the most damage on a child.  Far more than many of the other drugs, alcohol seemed to be the worst.  What is so surprising about that is that many of us drink alcohol.  We don’t believe that we need counseling or anything because we don’t have alcohol or substance abuse-types of problems. 


It is a serious problem when it comes to having babies.  I really do not believe that the general public understands how critical it is.  When Senator Wiener talked about [people thinking], “Well, maybe a baby is drunk,” it’s not just that.  It’s the deformity of the child’s face and the mental retardation that they experience all because of drinking alcohol during that pregnancy.  It’s far more serious than I had ever realized, so I personally, actively, support this legislation, too.


[Ms. Foley, continued]  I know the Restaurant Association has talked in the past about, “Well, we don’t want you to interfere in our business,” but posting of a sign is just critical and could make all the difference in the world.


Tim Crowley, representing the Nevada Resort Association:

[Introduced himself]  Our member companies make up several bars, restaurants, and clubs in Nevada.  We want to express our appreciation to Senator Wiener for bringing this bill forward and offer our assistance in doing whatever we can to address this very serious issue.


Chairwoman Koivisto:

Any questions from the Committee?  [There was no response.]  I don’t see anyone else signed up in support of S.B. 307.  Down in Las Vegas, Van Hefner has signed up in opposition.


Van Hefner, President/CEO, Nevada Restaurant Association; President/CEO, Nevada Hotel and Lodging Association:

[Introduced himself.]  We represent over 700 restaurants and we also represent over 182 hotel casinos.  [Our members] employ over 160,000 people. 


I certainly am very aware of the concerns about fetal alcohol syndrome.  We also agree with whatever we can do through the educational and health arena to really provide the education to the mother during [her prenatal] care.  To us, the first step is the educational programs in our schools, junior highs, and high school health classes.  In addition, the next phase [of education] is the health care provider, the physician, the certified nurse, midwife, and the other people who educate.


Our concern is the sign issue.  This is not the only sign that is coming at the restaurants or our facilities in the lodging industry [which include] issues such as allergies to shellfish, seafood, and peanuts, obesity, any of those.  There are various groups that have surfaced [and requested] additional posting of signs throughout our operations.  I’m coming [before] you today because of our concern for numerous signage [requests].  [We’re] not debating what we need to do from a health standpoint.  This is just additional activity on our restaurants and our businesses that, in fact, is not where the illness lies.  It needs to be in the educational program and the health care community.


I took a potential compromise to both of our groups and the restaurants unanimously are opposed to additional labeling including warnings such as this in our establishments.  This is not the only warning we have to have; there are many, many other [warnings] from raw eggs to shellfish and other issues.  I do appreciate you understanding [our objection is] about additional warning labels in our operations.   


Chairwoman Koivisto:

The bill on page 4, line 27, says that the sign can be posted in the women’s restroom.  Would that …?


Van Hefner:

That was Senator Wiener’s [idea].  That was a very positive move and some of our members accepted that but a majority, and I’m testifying on behalf of the entire membership, there was not one restaurant that agreed to that.  On the hotel/casino side, some of them did concur with that.  That is a step in the right direction.  If we [have to have] signage, that certainly would be less offensive.


One of the problems is, when bills are passed, somebody has to be responsible.  I’ve talked to both health departments and in the process of normal inspection they would check the sign off and [issue] the appropriate demerits, whether it would be one or two.  But I am coming at you on behalf of our membership.


Assemblywoman McClain:

If putting up signs is going to be a real big problem, how about every time a restaurant has a new menu printed, they have a disclaimer on there?


Van Hefner:

I’ll be candid with you.  A couple of the restaurants said they would rather have had that; however, now we have the raw eggs in Caesar salad and we have the shellfish, we have the cooking temperatures and so what happens is pretty soon your menu becomes…  A couple of the restaurant owners and operators said, “Why not on the back of a menu?”  Maybe if there were a couple of choices, depending on the establishment.


Let’s face it, Bellagio also has food in their lounge areas.  If it’s posted in the women’s restroom, which area?  If we could have a couple of choices, maybe that might [better] serve the proprietor.


Assemblywoman McClain:

The raw eggs and the seafood, people probably already know if they’re intolerant to that kind of stuff.  What I think is the problem with alcohol and pregnancy is that society has [received] very mixed messages.  On one side you hear that a drink a day is good for your heart, and I tend to agree that probably most women do not understand how serious it could be.  Not that it always will be, but that they’re taking a huge risk.  I just don’t see a problem with at least having a sign or something just to remind women that this is a possibility; this is something they need to look out for and to take care of themselves.


Van Hefner:

I’m the author of “Serving Alcohol With Care” that the entire industry uses and a graduate of the University of Utah Medical Center, so I understand the alcohol issue.  At the same time, we’ve got to get the message out there.  I was interested in [what] Senator Wiener’s response was to all the tavern people or people who are only serving alcohol by the drink.  I know we have restaurant licenses but some of those would be under a different license, I believe.  It’s a personal concern for me, too.  If you give us a couple of choices, whether they put it on the menu or they put it in the restroom, maybe those two might be a compromise that might best fit with the ambiance [of the establishment] as well as get the word out.


Assemblywoman McClain:

I wonder how the author of the bill feels about putting it on the menu.  It would seem to me that it would be much more noticeable than a little sign by a cash register, or something.


Senator Wiener:

I offered the [language] “including, without limitation, the women’s bathroom” with the hopes that we could come together on something.  It’s just my hope that we have the opportunity to get [the message] out and that we know that the customer would be able to see the message.  I would certainly be willing to work with the Committee. 


One thing we need to remember about education is that, as the article says, 15 percent of women drink during pregnancy.  In that article I passed out to you it says that doctors aren’t doing enough.  I would love to say that once we have the doctors in place giving [out] the message, we would never have to do this kind of thing.  There are still doctors who aren’t [educating their patients] and there are still women who are not able to access prenatal care.  Often the message is most powerful at the place where the behavior is occurring, where women are drinking. 


Again, if they’re thinking of getting pregnant or are already [pregnant], each subsequent drink would affect [the baby].  Wherever we could get a message…I know in California they do it.  They have it on napkins, too.  I would certainly be willing to work with the Committee as long as we could allow those who provide alcohol on the premises to help the educators as well.  We all have a responsibility; we all pay a price – $4 million per child additional social and economic and criminal justice costs. 


Assemblywoman Weber:

I’m a great believer of education on issues such as this.  To me a warning is an aspect of education but it’s just to get your attention.   When this was being drafted, was any thought given to including on the sign a phone number or something or who’s posting it, and why?  It seems very generic they way it currently is.


Senator Wiener:

The Health Division did an sign in English and Spanish and there is a phone number on that.  That was done in the interim to get something going on a voluntary basis.  This wouldn’t exclude that.  That’s the minimum [information] that would have to be on the sign.  Certainly, [information concerning] where you can get help or where you can learn more, that would certainly be invited.


As to the cost, as I said in my testimony I will be willing to pay for 10,000-15,000 signs if there is not funding otherwise.  If it’s on the menus, that’s a little different thing.  We’d have to negotiate that, but I’d certainly be able to provide the signs.  I believe in it very much.


Chairwoman Koivisto:

If we were to add something to the bill that, as an alternative, the warning could be put somewhere on the menu, would that would be acceptable to you?


Senator Wiener:

My sense would be that it wouldn’t be the basic 8½” by 11” requirement.  My request would be if it were on the menu, that it would be of a large enough point size so it could at least be read.


Chairwoman Koivisto:

We’d have to …[Senator Wiener added that it be large enough to be read in dark lighting; something reasonable that doesn’t overwhelm the menu.]  Right. 


Van Hefner:

I think that would be a very positive choice.  There are certain ones [where] the information would be better off with a menu, another one may be a women’s restroom.  If we could do an “either/or,” something like that might be more acceptable to the membership.

Senator Wiener:

The language is, “including, without limitation, the women’s restroom,” but that wouldn’t limit it to either of those two.  They could put “also posted somewhere else” the way we drafted it.  “Including, without limitation,” would not limit them to posting it, if they wanted to, next to the bar, or wherever.  That would be an even broader opportunity.


Chairwoman Koivisto:

Any questions or comments from the Committee?  [There was no response.]  We’ll bring S.B. 307 back to Committee.  Pleasure of the Committee?


Assemblywoman McClain:

I would like to see what anybody else thinks about the menu idea as another option.


Assemblywoman Pierce:

I’m okay with the menu idea if we said something like the font size needed to be the same size as the font size used on most of the rest of the menu so that the print is not [extremely small] and at the bottom.  I’d also like to leave the language in about putting it in the bathrooms.  I think that’s a good idea. 


Assemblyman Horne:

I agree with my colleague, Ms. Pierce, in part.  I wasn’t going to say anything because I know sometimes we have to pass legislation in bite-sized pieces, but I have a problem with the bathroom.  If you don’t visit the restroom, then it’s ineffective.  To me, “conspicuous” means that whoever it’s going to affect will be able to see it.  I like the menu idea for restaurants.  If we’re talking about a pub, maybe it should be at the door or on a sticker on the mirror if you’re sitting at the bar.  I don’t know why there are not stickers in the coolers in grocery stores when you go to open [them up].  If we’re trying to reach pregnant women who may drink while they’re pregnant, these types of warnings should be anywhere and everywhere that they may consume alcohol.


Assemblyman Hardy:

Dr. Mabey and I were wondering why we’ve never seen any of these signs.  The reality is you don’t go [to the restroom] unless you’ve already drunk something.  I concur with Assemblyman Horne’s concept that the more places [warnings are posted] the better it is.  I would be thrilled to have it on the menu, particularly on the drink menu or the beverage part of that menu where it would be appropriate to see. 


This is not unique to women.  We have an obligation as the father, as well.  It behooves us not to encourage behavior that would put at risk our child.  It is not just a woman’s issue; it is a family issue.  I suspect if we could put it on a menu or somewhere prominent long before we get into the restroom, it would probably be wiser.


Senator Wiener:

I enjoy coming to this house; I learn new perspectives.  I appreciate the sharing [of ideas].  It doesn’t say that it has to be in the women’s [restroom]; it could be just in the restrooms.  I agree.  I [had] thought that if someone were drinking, they would find their way into [the restroom] at some point during the evening.  “Including, without limitation,” [means] it could be posted anywhere.  That doesn’t mean [warnings] can’t be [posted] somewhere else as well, and it says “at least one,” it doesn’t mean only one [sign].


Chairwoman Koivisto:

My experience has been that the light is generally better in the restroom and you’re probably more likely to see it in the restroom.


Van Hefner:

In certain restaurants it would be very, very expensive to continue to redo menus and that sort of thing.  At the same time, if we could have an option, depending on what the situation is.  [There would be] a posting somewhere.  I wondered if the sponsor [of S.B. 307] might entertain that idea?


Senator Wiener:

That’s what the bill would read.  It does say “at least one conspicuous location including, without limitation, the women’s restroom.”  If we added the language, “or the menu” or whatever our [bill drafter could] come up with, it could be anywhere.  It says “at least one;” it doesn’t eliminate other postings as well.  That’s one possibility, but it could be anywhere.


Assemblywoman McClain:

Just to clarify—we don’t mean one menu.


Senator Wiener:

The word “conspicuous” was added for a reason so that it wasn’t posted in such a hideaway place [that it would only be observed by] someone who cleans up at the end of the day.  [The sign needs to be posted] somewhere where it will do some good and be observed by those who would be affected by what drinking could do to that unborn child.


Chairwoman Koivisto:





Marla McDade Williams:

Amend to include “require posting either on a menu in a font similar to the items on the menu or in a conspicuous place on the 8½ x 11 inch sign with the 40‑point font.”  [Assemblywoman McClain responded that that sounded perfect.]


Senator Wiener:

I have a little bit of background in publishing; more than font it would probably be point size.




THE MOTION CARRIED.  (Mr. Williams was absent for the vote.)



Chairwoman Koivisto:

Senator, [please] go ahead with S.B. 287.



Senate Bill 287:  Establishes Arthritis Prevention and Control Program to increase public awareness of and educate persons on matters relating to arthritis. (BDR 40-596)


Senator Valerie Wiener, Clark County Senatorial District No. 3:

I’m here to urge your support for S.B. 287, which would establish an arthritis prevention and control program.  This program would increase public awareness and educate persons on matters related to arthritis.  As with many of us, the newcomers will learn it’s a great experience to go to conferences where we could mingle with knowledgeable people.  We get some of our best ideas at legislative conferences.  I got quite interested in the issue of arthritis when I attended an NCSL (National Conference of State Legislatures) health leadership conference.  Learning about the universality of this health issue prompted me to bring this bill forward today. 


We know that arthritis encompasses more than a hundred diseases and conditions that affect the joints, surrounding tissues of joints, and other connective tissues.  We also know that arthritis is one of the most common families of diseases in our country because it affects nearly 1 in every 6 people.  By [the year] 2020, it will affect 1 in 5. 


The social and medical costs are staggering, exceeding $125 billion each year.  This is why the Arthritis Foundation, the Centers for Disease Control and Prevention, and the Association of State and Territorial Health Officials have taken the lead in developing a public health strategy known as the
National Arthritis Action Plan.


[Senator Wiener, continued]  Since beginning my work on S.B. 287, I’ve learned that our state has received some money to establish a program, and this particular legislation is intended to statutorily establish a statewide program.  This program will have an advisory committee and it will address the current and future needs of the people of Nevada.  S.B. 287 was written without a fiscal note because you will see throughout the bill language something like, “as money is available.”  However, by establishing the details of a program in statute, this shell of a program being in place, we will be able to go forward and receive many of the monies at the federal level that are available to such a statewide program.


In the interests of time, I’m not going to go through the bill section by section, but I’d certainly be happy to respond to any questions.  I’d just like to say that arthritis is the leading cause of disability.  When I went to that conference, I discovered that the first three kinds of arthritis were kinds I experience and I didn’t even know they were arthritis.  Most of us will experience it if we’ve ever had a health injury.  Children with sports injuries at some point will probably get arthritis.  As we try to lead active lifestyles it’s something we need to be aware of, and this kind of program statewide, established in statute, could help us not just address what happens once you get it, but certainly help us be better‑informed and better-educated consumers of health care products, needs, and services, and maybe one day be able to prevent arthritis from affecting our lives.


For these reasons, and so many other reasons, and because of its ever-present nature in our lives, I urge your support for this program established in S.B. 287.  [We need to] move forward with this important health mission and be able to show a statewide commitment, through statute, to such a program, and go after the money to help us get that information out to the public.


Chairwoman Koivisto:

Questions from the Committee?


Assemblywoman McClain:

What’s the funding mechanism on this commission?

Senator Wiener:

It’s as money’s available.  A lot of it will be grant money.  There is money in the state now; they’re just starting and we do have the person who is working in the Health Division to testify.  We are not caught up with other states [in establishing] a statutory program so it’s not just at the whim of a progressive director, but that we have something in place to show our commitment.  That would certainly help us get more money.  The CDC (Centers for Disease Control and Prevention) has money, the Arthritis Foundation has money, and because [arthritis] is such a large [enervator], I’m hoping that this will allow us to go after a lot of funding at the federal level.


Assemblywoman McClain:

That was my question, how this would work with the Arthritis Foundation, but you just answered my question. 


Assemblyman Hardy:

What [forms of arthritis] are we preventing other than the “wear-and-tear” kinds of arthritis?  There are [many forms of arthritis] that are caused by the rheumatoid family.  I suspect that those [forms of arthritis] are included in the Arthritis Foundation-type things and I don’t know that we can prevent them.  Will this allow those likewise to be benefited in some way?


Senator Wiener:

When it comes to the details, I would think we have a better expert to testify on that than I.  Prevention would probably be what we could strive for.  As you say, much of it we can’t prevent, but knowledge may help people, even if it’s striving to teach people how to be safer in how they participate in their sports and in their life activities.  That may, in itself, help prevent some of the types of arthritis. 


Because I know how important it is to live healthy lifestyles, one of my hopes would be to encourage people who have arthritis to learn that they can live healthy, active, productive lifestyles and not succumb to stereotypes about arthritis.  It’s amazing when you talk to people, “oh, that’s in the family of arthritis.“  It’s amazing how many issues fall into that arthritis family.  It would be my hope at some point that we could teach people how to be safer in their life choices in terms of activities so they wouldn’t even incur some kinds of arthritis. 


Assemblyman Mabey:

I’m following up on what Dr. Hardy said.  There are a lot of autoimmune disorders that affect people and those, to our knowledge, are not preventable.  I would like people who have autoimmune disorders [to] be included in this.  With arthritis we think of osteoarthritis, but people get different autoimmune disorders, rheumatoid arthritis, systemic lupus, and there are many different conditions that have problems with arthritis.  Hopefully, those types of conditions would be included in this, too.


Senator Wiener:

Ditto.  As I foresee it, this would not be exclusionary; it would be inclusive and I speak from very sad experience.  I lost a sister-in-law to lupus, [which] also is in the arthritis family.  My sense would be since there are at least a hundred kinds of arthritis, that this certainly would be included.  The very nature of the diseases you’re talking about needs to be addressed as well.


Chairwoman Koivisto:

I think probably the things it addresses are probably limited by the National Arthritis Action Plan established by the Arthritis Foundation, et cetera, in Section 2, sub 2.  If those things are part of that; then I’m sure they’re part of this.


Senator Wiener:

We do have an expert here who could respond more directly than I can who is helping to set up the program for the state.


Kim Neiman, RN, MPH, CIC, Diabetes Prevention and Central Program, Health Division, Department of Human Resources:

[Introduced herself.]  The state Health Division has recently received a grant of $100,000 from the Centers for Disease Control and Prevention to address the prevalence of arthritis in Nevada.  A continuation grant was submitted to CDC for fiscal year 2004 and it is expected that at least level funding will be awarded.  S.B. 287 requires the state Health Division to establish an arthritis prevention and control program to increase public awareness and to educate persons regarding arthritis.


Funding from the CDC is currently being used to implement the requirements as outlined in this bill.  One objective of the new arthritis prevention and control program is to establish an arthritis coalition with both public and private membership.  This objective has been met.  The coalition became effective in February of this year.  This partnership will develop a population-based approach to arthritis in Nevada.  The Health Division appreciates the opportunity to address S.B. 287 and to recognize the importance of arthritis as a chronic disease. 

Chairwoman Koivisto:

Who’s on this committee?  Do you have medical experts [like] rheumatologists on this committee?


Kim Neiman:

Yes.  We held our first meeting in February.  We’ll be holding quarterly meetings and our next one will be later this month.  We have medical experts, and Dr. Teresa Chavez here in Carson City, a rheumatologist, is our chairman.  We also have Dr. Prupas from Reno, and we have representation from the University of Nevada School of Medicine.  Other physicians are not involved at this time but we are inviting others to be involved.  We’ve had one meeting and in this first meeting, which had 20 different organizations represented, we invited others to let us know who else should be included and invited to come.  We’ll find out at this next meeting who else will be there.  We also have representation from the Clark County Health District, Washoe County Health Department, the YMCA, private citizens, and many others.


Donna Johnson, Director, Northern Nevada Branch of the Arthritis Foundation:

[Introduced herself.]  I’m here to support Senate Bill 287.  People need to realize how serious arthritis is and that it not only affects older people, it affects many children.  As a result of my own personal experience with rheumatoid arthritis I really know how important the passage of this bill is.  I’ve had arthritis for 40 years.  I have it in the majority of my joints.  It also affects my eyes.  I think people need to be aware of the fact that it’s not only a disease of the joints; it’s also systemic.  People need more information and education regarding arthritis.  They need to realize they can take control of their lives by becoming proactive and becoming involved in some of the programs that are available now and will be available to them in the future.


Chairwoman Koivisto:

Questions from the Committee?  [There were none.]  I don’t have anyone else signed in to testify on S.B. 287 so I’ll bring S.B. 287 back to Committee.  Pleasure of the Committee?






THE MOTION CARRIED.  (Mr. Williams was absent for the vote.)



Next we have S.C.R. 11.



Senate Concurrent Resolution 11:  Urges Department of Human Resources to establish statewide informational and referral system for health, welfare, human and social services. (BDR R-680)


Mary Liveratti, Deputy Director, Department of Human Resources:

[Introduced herself.]  With me is Todd Butterworth, Acting Director of the Office of Community-Based Services.  We are here today to support the development of a statewide information referral system with access by dialing 211.


The Strategic Plans for People with Disabilities and for Seniors, authorized by Assembly Bill 513 of the 71st Legislative Session, recommended that both a 211 universal access line with supplementary “no wrong door” website and community-level call centers be established.


The strategic plans recognize the need for information that is current, accurate, and easy to access.  Families often do not know where to go for assistance.  Consumers and families cannot make the best decisions on how their needs may be met if they are not able to access reliable, appropriate information, referral, and assistance.  The strategic plans also acknowledged the need to coordinate services as a means to avoid confusion for the consumer and reduce service duplication.  This system would allow for a greater knowledge of the resources available and could be designed to assure referrals are offered more appropriately by screening for location, financial resources, and other pertinent data related to consumers. 


An additional benefit of this system would be data collection.  Data from the system could be used for future strategic planning.  For example, service needs that are not currently being met by available resources would be identified.  Currently, it is difficult to gather and use this information effectively because it is not compiled, or comparable, in some cases.  All of the strategic plans identified the need for improved data systems for future planning efforts and accountability.  This system would enable the completion of information on an ongoing basis and could provide statistics for budgetary and legislative purposes. 


Although S.C.R. 11 designates the Department of Human Resources as the agency responsible for establishing and maintaining the 211 system, we believe very strongly that this system must be developed as a public/private partnership.  Establishing a 211 system will require a commitment by multiple public agencies such as Human Services and the Public Utilities Commission, and also private agencies such as United Way.  We envision the 211 system being operated by a private entity such as the United Way.  United Way agencies have provided leadership in this area in many states, including Nevada.  Anne Cory, President and Chief Professional Officer of the United Way of Northern Nevada and the Sierra, presented a proposal to the committee for the study of state programs for providing services to persons with disabilities on September 10, 2002.  In addition to describing the benefits of the system, Ms. Cory also emphasized the many planning tasks that would need to be accomplished before implementing a 211 system.  Some of these tasks include:



In summary, we support the development of a statewide system for information referral on health, welfare, human, and social services with accessibility through 211 calling.  The system would provide streamlined access to existing services for our citizens and would provide improved information for future community planning.  The Department of Human Resources will continue to work with our community partners to develop a business plan, identify funding sources, and determine the best implementation strategy.


Vice Chairwoman McClain:

I think this is the big umbrella that the single entry point is working on right now.  Can you bring us up to date on how they’re coming along on that single‑point-of-entry computer system?  Let me give you a little background first.  This is a group that’s been meeting for a year or a year and a half.  It’s under grant funding.  I got involved in it because of the senior advocate program in Clark County.  It’s a great concept.  They’re not to the point where it’s really doing anything yet.  I think Clark County Social Services is almost to the point of agreement of maybe being able to design this computer system and use it as a model for the statewide system. 


It’s designed for seniors, basically.  What we looked at is Web-based so that if someone calls the senior advocate program we can get them in contact with the right agency, or if they walk into the Division on Aging Services, they can do the same thing.  Everybody will have the same information.  There would be a simplified data entry screen because you don’t want somebody at my offices or Lutheran Social Services taking confidential information from people.  Then when it gets to the right agency, they will then collect the information they need for eligibility on their level.  Tell me if I’m right and that this will be the big umbrella eventually.


Mary Liveratti:

Yes, the Division for Aging Services had a planning group, as you mentioned, for almost the last two years now.  Through some federal grant money we received as the National Family Caregiver Support Program, they began a series of meetings and trying to build the coalitions to have what they call a single point of entry.  The disabled community has been calling it a “no wrong door” and I kind of like that better because I think many people don’t understand “single point of entry.”  They think there’s only one place to go to access information.


With either system what we’re really trying to do is, wherever you access, whether it be through the phone, walking into an agency and asking questions, or whether you go to the Web site that will be developed, you can get a comprehensive listing of services available and also some identification of what your needs are.  Both the “single point of entry” and “no wrong door” concepts actually go beyond just an information referral call line in that, when we get there, and it will be a few years from now, we would really like to have some care coordination.  Rather than the family member, who’s already in a crisis state, being sent to multiple agencies to get that information, we would hope that they could come into the no wrong door, single point of entry, [and get more than just a list of phone numbers].  The care coordination piece would come in to make sure that either they’re able to access those services or, if not, that there’s some more intervention by the system to help the family.  [The system might even] identify needs that we don’t have resources for, so we would look at service gaps also.


Vice Chairwoman McClain:

That’s absolutely true.  It’s a great concept.  I was made aware of one in Oklahoma City.  They call it “gateway” or “gateway to care.”  It even goes one step further.  It will allow people, like a pharmacist or a store clerk who knows a senior well, to be able to go to this entity and say, “I think I have some concerns about this.”   They actually have an intervention team that will go out to the senior’s home and [offer assistance].  They’re trying to avoid a dangerous [situation later].  The senior always has the option to say, “No, I’m fine.”  You can’t force yourself on them.


It’s the whole community-based coordination of care that’s going to help seniors and the disabled to function in life.  It’s everything from medication management to getting the services you need, if nothing more than a social life and transportation and things like that.  I fully support this.  I just wanted you to explain where we’re at in this particular process.


Does the Committee have any questions?  [There were none.]  Do we have anybody else that wants to speak on S.C.R. 11?


Jon Sasser, Washoe Legal Services:

[Introduced himself.]  I had the pleasure to serve on the interim committee for people with disabilities under A.B. 513 of the 71st Legislative Session.  This was one of our centerpieces of where we would like to move over the next ten years.  I’m here to urge you to urge the Department to move forward over the next two years to come back with something in 2005.


Vice Chairwoman McClain:

I think 211 is becoming a nationally recognized number.  In the next few years everybody’s going to be saying, “Why don’t we have it?”


Mark Nichols, Executive Director, National Association of Social Workers, Nevada Chapter [NASW]:

[Introduced himself.]  I’m here to speak in support of S.C.R. 11.  The NASW office in Las Vegas is listed in the yellow pages under “Social Workers” even though we are the professional association.  I will get three to five calls per week when I’m in the office from people who are trying to figure out where the Social Security office is or what the telephone number is, to people who are in crisis.  While I’m not a social worker, it’s just a one-person office, they’ve reached the wrong person by talking to me, but I’ve tried to get to what their need is and get them connected with the service.


[I have] a couple of observations.  I frequently get comments that, by the time they’ve reached me, they’ve tried navigating their way through our system and are frequently very frustrated.  I occasionally will get comments that, “At least when I called this number, I talked to a human being, didn’t have to listen to a machine and figure out whether I want to push number three or number four.”  I think that’s a critical component of this.  Frequently these are people who, to a certain extent, just need somebody to listen to them. 


[I have] another concern [but] I don’t know if it can be built into this.  Because we’re such a transient community, I will occasionally get calls from people in [other states] saying that they just got off the [phone] line with their uncle who lives in Las Vegas and, “He has no other family member and he sounds like he’s in crisis.  How can I get connected with services?”  By the time they’ve reached me, they may have made several long distance phone calls to get to talk to me.  If there could be a way they could reach somebody, albeit the wrong person, and we could direct them to this service it would be fantastic.  I don’t know if they could just dial [the area code] and then 211.   Maybe the Internet is that route.  I urge your support.  It is a critical need in our community and this represents good public policy.


Vice Chairwoman McClain:

I might put in a plug for the senior advocate program who also have live bodies answering the phone.  So, if somebody needs some help in Clark County and you’re a senior or a senior’s care giver, call the Clark County Senior Advocate Program, that’s what it’s designed to do.  It’s (702) 455-7051.


Any questions from anybody else?  [There were none.]  Do we have anybody else who wishes to testify?  [There was no response.]  Any questions from the Committee?  [There were none.]  Then we can bring S.C.R. 11 back to the Committee and I’ll take a motion.






THE MOTION CARRIED.  (Mrs. Koivisto and Mr. Williams were absent for the vote.)



[Vice Chairwoman McClain, continued]  We have a couple of bills on work session and our Chairwoman had to go testify [in another committee].  [Assemblyman Mabey inquired which bills were on the work session.]  It was Senator Amodei’s bill about the qualifications of the State Health Officer and Senate Bill 411 about the qualifications and appointment of the State Health Officer. 


Let’s let Marla go through it and we’ll see if we want to handle it.


Senate Bill 332 (1st Reprint):  Revises qualifications of State Health Officer, clarifies restrictions on use of “M.D.” title and makes various changes relating to licensure of physicians and Board of Medical Examiners. (BDR 40-1036)


Senate Bill 411 (1st Reprint):  Revises certain provisions relating to qualifications and appointment of State Health Officer. (BDR 40-1243)

Marla McDade Williams, Committee Policy Analyst:

The work session document (Exhibit E) shows that Senate Bill 332 was heard by the Committee on April 30.  It revises the qualifications of the State Health Officer, clarifies restrictions on the use of the title “M.D.,” and makes other changes concerning licensure of physicians.


[Marla McDade Williams, continued]  At the hearing on the bill, the Board of Medical Examiners expressed concern with Section 7 of the bill.  The Board’s representative offered an amendment to this section and he expressed a desire to add language allowing the Governor to declare an emergency in certain situations.  The emergency declaration would result in the Board waiving certain licensing requirements for certain types of practitioners.  The person on whose behalf the bill was introduced does not support the amendments, particularly the amendment to Section 7.


This measure was heard at the same time as Senate Bill 411, which also makes changes to the requirements of the State Health Officer.  That bill, S.B. 411, was requested by the Department of Administration.  No testimony was provided in opposition to the bill.  It appears, however, than if S.B. 332 were enacted it would negate the need for Section 1 of S.B. 411.  Section 2 of S.B. 411 contains language clarifying that the position of the State Health Officer is an unclassified position that serves at the pleasure of the Director of the Department of Human Resources.


During the hearing on this bill there was discussion of sending it to the Commerce and Labor Committee to possibly address the licensure aspect of the bill.  If the Committee felt more comfortable looking at the State Health Officer language [it could then] send on the other part.  The amendment is not included because of that discussion we had.


The Chairwoman and I discussed, if the Committee were interested, amending the Section 2 language from S.B. 411 into Senate Bill 332, [which would] put [the State Health Officer] in the unclassified service, and then forwarding on Senate Bill 332 with that one amendment to Assembly Commerce and Labor.


Chairwoman Koivisto:

I missed the first part of the conversation but what we talked about was, because most of S.B. 332 deals with licensure, which this Committee does not deal with, we thought we could take subsection 3 in Section 2 of S.B. 411, “the State Health Officer is in the unclassified service of the state,” and make that subsection 3 of Section 1 in S.B. 332.  We will then re-refer S.B. 332 to the Committee on Commerce and Labor because they deal with the licensing issues.  The only section of S.B. 332 that falls under the purview of the Health and Human Services Committee is Section 1.  Questions?  Comments?  [There were none.]


All we would take from S.B. 411 would be subsection 3 of Section 2 on page 2, “The State Health Officer is in the unclassified service of the state.”  We would amend that into S.B. 332 under Section 1 and it would be a new subsection 3.


Assemblyman Mabey:

What would happen with S.B. 411?


Chairwoman Koivisto:

We really don’t need S.B. 411 because [it] is covered in S.B. 332.


Assemblyman Mabey:

Except for that part, “or have a master’s degree in public health from a four‑year accredited college…?”


Chairwoman Koivisto:

I’m not sure that we want to have a State Health Officer who isn’t a doctor because the State Health Officer has to be able to declare a quarantine, make assessments of disease outbreaks, et cetera, and I’m not sure that someone with an M.P.H. is qualified to do those things.


Assemblyman Mabey:

I agree with you. 






THE MOTION CARRIED.  (Mr. Williams was absent for the vote.)




Senate Bill 179 (1st Reprint):  Makes various changes related to mental health. (BDR 39-480)


Chairwoman Koivisto:

We heard S.B. 179, which was the bill concerning persons with mental health issues being detained in a facility and perhaps being in an emergency room for a long time before they would be taken to a facility.  The question was when did the 72 hours start.  I have an e-mail I received from the Disability Advocacy and Law Center.  This would amend NRS 433A.150, Section 10, [subsection] 2 of the bill.  This would change it to “except as otherwise provided in subsection 3, a person” and then it would delete “admitted to a mental health facility or hospital under subsection 1.”  That would be replaced with, “detained pursuant to subsection 1.”


[Chairwoman Koivisto, continued]  We’re on page 5 of the bill, Section 10, line 16.  It would take out “admitted to a mental health facility or hospital under subsection 1.”  It would take out that whole line and replace it with, “detained pursuant to subsection 1.”


Then go to line 18 and delete, “from the time of his admission” and that would say, “after he has received the examination required by NRS 433A.165.”  “To that facility or hospital” would have to come out of that line, too.  So the paragraph would read, “Except as otherwise provided in subsection 3, a person detained pursuant to subsection 1 must be released within 72 hours, including weekends and holidays, after he has received the examination required by [NRS] 433A.165, sub 1(a), unless within that period a written petition …”


Assemblywoman Leslie:

I think that’s actually a very good amendment.  It came from the Disability and Law Center and I think it answers my concern about the due process so we don’t have people just sitting in the emergency room for who knows how long until somebody can examine them.  This way, as I understand the amendment, they would get examined and then the clock starts, so the state then is responsible for, [in] 72 hours, moving them to a more appropriate facility.


Chairwoman Koivisto:

That’s correct.  It reflects the reality that emergency rooms have to prioritize based on considerations of medical necessity.  That way the time limits don’t start until somebody’s been examined.


Assemblywoman Leslie:

I think that’s a good compromise.


Assemblywoman Pierce:

Is this “examined” by just the physician in the emergency room or is this by a psychiatrist?

Chairwoman Koivisto:

Right, it’s a physician, licensed physician assistant, or advanced practitioner of nursing.  Whoever does the examination in the emergency room.


Assemblywoman Pierce:

And that’s when the clock starts?


Chairwoman Koivisto:

That’s when the clock starts.


Assemblyman Hardy:

The term “examination” is not a definite period of time.  There comes a point where there is a diagnosis made and a plan is done.  The way the doctor thinks is, they assess the person by history—what happened, what’s going on—and they do a physical examination which includes laboratory testing.  [There might also be] laboratory tests, x-rays, a CAT (computerized axial tomography) scan, or an MRI (magnetic resonance imaging).  All of that takes a period of time.  They put the history together with the examination and the laboratory examination to make a “diagnosis.”  Once the diagnosis is made, then they make the plan or the prognosis or the treatment.  That part of the treatment is when I would say the clock starts because that requires consultation so the [health care professional] may not be in the position to make that determination as to what the ultimate plan is for this person until he or she has talked with the consultant, the psychiatrist on the phone, or had the consultant come into the emergency room, or whatever other facility, to say, “This is what you missed, you didn’t miss that, have you considered this, have you considered that.“   The actual plan is after the examination.  The examination is only part of that process before you’re able to make the plan.


You’re going to be in the emergency room probably for a minimum of two to six or eight hours while you’re determining what’s going on with this person, because you have to observe them from a clinical standpoint.  It would be unusual to say, “I talked to the person, I examined the person, and now I know what I’m doing.”  You’re going to have to rule out diabetes, a thyroid storm, head trauma, subdural hematoma, subarachnoid hemorrhage, [et cetera].  You’re going to have to look at all of those things and that’s going to require the CAT scan [and/or] the MRI to figure out why this person is acting the way the person is.  The term “examination” is not a definitive time period.  It’s when you get the diagnosis and have had the consult that says, “This is the safest place for this person.”  I’m a little uncomfortable with the term “examination.”  Once you’ve made the diagnosis, the plan usually happens very quickly.  You could even say, “on completion of the examination” and that would probably be closer to the reality.  That would encompass all the peripheral things you have to do to get the diagnosis.


Marla McDade Williams:

If I could direct the members attention to Section 11 on line 34—when you read the proposed amendment in conjunction with that section it says that, “Before an allegedly mentally ill person may be transported to a public or private mental health facility…the person must first be examined by a licensed physician or physician assistant or an advanced practitioner of nursing to determine whether the person has a medical problem.” When you read the proposed amendment in conjunction with that, Dr. Hardy, does that address your concerns?


Assemblyman Hardy:

Does Section 10 reference down to Section 11?


Marla McDade Williams:

The amendment that the Chair was reading would amend subsection 2 to say, “Except as otherwise provided in subsection 3, a person detained pursuant to subsection 1 must be released within 72 hours, including weekends and holidays, after he has received the examination required by NRS 433A.165,1(a) and I think that’s the reference back.


Assemblyman Hardy:

I would feel comfortable with the intent and I would claim ignorance on 433A.200.  I don’t know what’s in there.


Marla McDade Williams:

I’m sorry, that should be the language that is in Section 11.


Assemblyman Hardy:

So it’s not in there now, but we can put it in there?


Marla McDade Williams:

No.  It’s in there.  That citation I just read is the language in Section 11.


Assemblyman Hardy:

So you’re referencing the whole part of [NRS] 433A, not just point 200 or point 150?


Marla McDade Williams:

I’m referencing what would basically start at line 32.

Assemblyman Hardy:

That makes sense to me.  If we’ve taken everything and we’ve done everything and we’ve got the psychiatric diagnosis and now we know where we’re going with that psychiatric diagnosis, that is the diagnosis and that would be okay at that point.


Chairwoman Koivisto:

The way I read it, that would be the examination to determine whether the person has a medical problem other than a psychiatric problem which requires immediate treatment.  If it’s determined at that time that the person has a medical problem, then he would be treated there.  If it’s a psychiatric problem, then he would be admitted to the mental health facility.


Assemblyman Hardy:

I think that is appropriate because in the emergency room, if we’re talking about that, they can institute the appropriate medicine in the emergency room.  They do not have to wait for that person to go to another facility to start the medicine.  I think that is one of the issues—how long are you going to wait before you treat this person and you have 72 hours to get the medication onboard.  There’s no reason to wait for that person to be in another institution to start the treatment.  The kinds of things we’re talking about are not group therapy; this is medicine we’re talking about.


Chairwoman Koivisto:

Right.  I think the problem many people had was that there was a fear that someone could be held for a lot longer than 72 hours and it was really a violation of their rights.


Assemblyman Hardy:

A person can actually be held longer than 72 hours but that has to go to the judge to be cleared.  The facility that is dragging their feet or can’t move fast enough has an obligation to, within that 72-hour period, apply for a more lengthy commitment of some kind. 

Chairwoman Koivisto:

Further discussion from the Committee?  [No one responded.]  Pleasure of the Committee on S.B. 179?  Do we want to move ahead with it?






THE MOTION CARRIED.  (Mr. Williams was absent for the vote.)


[Chairwoman Koivisto, continued]  Is there anything else to come before the Committee?  [No one responded.]  Okay, we’re adjourned [at 3:19 p.m.].








Terry Horgan

Committee Secretary








Assemblywoman Ellen Koivisto, Chairwoman