Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Good morning. This is Senate Health and Welfare. It's Tuesday, February 24, and we're going to look at the latest markup draft of S163. Jen, you wanna walk us through it? Sure, Jen Carvey from the Office of Legislative Counsel.

[Jen Carvey, Office of Legislative Counsel]: I'm actually just gonna start with the bill as introduced to remind you what this is, because the amendment is one very small instance of amendment. So this is S-one 163, an act relating to the role of advanced practice registered nurses in hospital care. You remember, we've gone through this one a few times. It specifically adds advanced practice registered nurses, or APRNs, to statutes on hospital patients' bill of rights and licensing of hospitals, recognizing that per their scope of practice, they may be the person who is attending to a patient who can be with the attending provider or a patient who's in the hospital, to recognize them throughout, that it's not just physician, seen in a lot of these roles. The amendment itself deals with this underlying language here on lines 13 through 15 of page two. This is in the Hospital Patient Bill of Rights, and it says that the patient shall have an impending physician and bill adds, or APRN who's responsible for coordinating nurse care. And then there's a second sentence that requires physician consultation and support to be available to an attending APRN at all times in accordance with applicable standards of practice and regulatory requirements. And you heard testimony from OPR and others that that language was not only not necessary, but actually potentially narrowed the scope of practice that is otherwise allowed for impairments. So the amendment simply takes out the version of that subdivision that has Who's the magnet? Is it? OPR? OPR? I mean, it's in the nurses. Okay. Where did the Yeah, think the APR was the one who was like, I think the APRNs were okay with removing that language, but I won't let you I have no idea. No, no, we talked about it. Thank you, though. Yes. You're right. Oh, it's alright. No, that's okay. I think the aberrants were comfortable with that as well. Don't we'll speak for them, let them speak for themselves, but I don't think you heard it in terms of that. So this is the amendment. Simply in section two strikes out subdivision A2, which was the part that had the second sentence, and inserts and move thereof, a new subdivision A2 that just says the patient shall have an attending physician or APRN who's responsible for coordinating her care. So it takes out that second sentence. Didn't seem that's definitely this doesn't change the fact that hospitals have their own biologics. Right, hospitals have their own policies, they have credentialing requirements. They may have consultation or supervision requirements.

[Committee Assistant (Temporary Clerk)]: Oh, let me look back up.

[Jen Carvey, Office of Legislative Counsel]: Right, this doesn't change any of what hospitals are doing. It is really a recognition of what does occur and is permitted under existing law to occur. So again, that's adding APRNs throughout the Bill of Rights for Hospital patients, anywhere a physician is, and updating some of language in those statutes to get rid of gendered terms, and just use non gendered terms like the patient. That law is in the bill, as it came as As it was in big section. Yeah, and then some of the disciplinary language, also recognizing right now some of the statutes are very specific to physicians who are licensed through the Board of Medical Practice, which does not recognize that there are physicians, osteopathic physicians, who are licensed through the Office of Professional Regulation, and then adding specifically the reference to a parent, so also then adding some references to OPR as the licensing authority. And then in section three is the hospital licensure requirements and certain minimum standards that a hospital must meet, and in that case, right now the statutes say all patients admitted to the hospital shall be under the care of a state registered and licensed practicing physician as defined by the Law of the State of Vermont. This changes that to a physician licensed pursuant to 2017 SA Chapter 23, which is the allopathic physicians licensed by the Board of Medical Practice for 33 osteopathic physicians licensed by OPR, or an advanced practice registry nurse licensed under a specific sub chapter for APRNs. So, OPR only licenses the osteopathic APRs? No, they licensed osteopathic physicians. And And a number of other healthcare professionals. The board of medical practice licenses medical MDs, so different, slightly recruiting, but I believe same scope of practice as osteopathic physicians. Allopathic physicians, medical doctors, physician assistants, podiatrists, anesthesiologists, radiologist That's scope of what they

[Committee Assistant (Temporary Clerk)]: Oh my gosh. Board medical. Board medical.

[Jen Carvey, Office of Legislative Counsel]: Board Board medical staff. There's the MDs, so DOs are the osteopathic physicians at OPR, so when you go to see the doctor and you are seeing a physician, you may not know whether that physician is an MD doctor or a DO doctor, because they do the same things. But the MDs are licensed through Oregon Medical Practice and DOs are licensed through OPR. And then Oregon Medical Practice also licenses physician assistants, podiatrists, I believe radiologist assistants, or anesthesiologist assistants. I think that is their method of what they license. And then osteopathic physicians, nurses, including APRNs, mental health professionals, and the other providers are I'm sorry about that. OD. It's an art of a historical How did the OD's end up in DOs. We do not. How did the DOs end up in Right. OD's are the The optometrist. Alright. Delia is on. Also over the house. That's what I was gonna ask you. Here's our proposal here, right? So, well then, this is just the last reference in the bill to adding that case records must be signed by the attending physician for a parent, and the aggregate effect of the passage. So, yeah, so the only amendment I have so far as we reviewed is that one small change to take out the reference to consultation being required as part of the Hospital Patient Bill of Rights, but does not change what a hospital may do to their own policies. So, really, this bill, what does this bill do overall? This bill, I think, as I understand it, recognizes that, it recognizes in the statutes that there are rules that APRNs are permitted through their licensure and scope of practice to perform in hospital settings, but the statutes currently refer only to physicians. So, it's adding in the APRNs and as appropriate references to the Office of Drug Recognition.

[Committee Assistant (Temporary Clerk)]: Think so. I think as I understand it, that a nurse practitioner could not be designated as the caretaker for an individual in the hospital even if the hospital's rules said that they could, but statute doesn't say that the judge

[Jen Carvey, Office of Legislative Counsel]: You think as a matter of practice that may be what's already happens, because it's not so much that the statute's currently prohibited, that they, reference to is required for other purposes, for satisfying the hospital patient bill of rights, or licensing the hospitals, that there is a physician in those roles, which at least I understand is not necessarily consistent with current practice, because of the scope of practice that is authorized for any burns. There's a bit of a disconnect. It was what? So what would would the committee like to proceed with this with the supposed amendment I'm open to either considering a vote now or we can hold off until at the end of the meeting today Right early in the morning, although I don't know if I'll to be hear from you. I'll make a motion to vote favorably on past one sixty three draft one twenty one amended.

[Sen. Virginia "Ginny" Lyons (Chair)]: And then it's well, you first, you wanna vote the amendment. Yeah. Okay. Then you vote the bill. I think there's a business. So If you I would like to make a motion to vote on the amendment of pass one sixty three. Discussion on this. And senator Morley, obviously, the article. Any any discussions? Questions? Okay. Where's our clerk? You're temporary clerk. It's draft one number one. Wait. Yep. Draft 1.1. That's my floating. This was some of the.

[Committee Assistant (Temporary Clerk)]: K. Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes.

[Committee Assistant (Temporary Clerk)]: We'll we'll wait for we'll get it both. Yeah. Yeah. We'll vote off on the action.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's the amendment. That will vote on the bill as amended. I'll move to vote on the bill s one sixty three as amended.

[Committee Assistant (Temporary Clerk)]: Want to do discussion? Right now. Yes. Hold up to the old senator and.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. No. We're going to both of them, and he's. We looked at s two thirty nine already. Two. It's not be It's Katie. It's Michelle, I think. Yeah. She you could save them wrong if she looked really problematic. Alright. We'll be

[Committee Assistant (Temporary Clerk)]: I got it.

[Sen. Virginia "Ginny" Lyons (Chair)]: You got it. You don't do it. Nice.

[Committee Assistant (Temporary Clerk)]: Alright. So

[Sen. Virginia "Ginny" Lyons (Chair)]: Any any further discussion? Okay. Let's go.

[Committee Assistant (Temporary Clerk)]: Good. Senator Mentz? Yes. Senator Cunning? Yes. Senator Gulick?

[Sen. Martine Larocque Gulick (Vice Chair)]: It's an I I.

[Committee Assistant (Temporary Clerk)]: I know.

[Sen. Martine Larocque Gulick (Vice Chair)]: I I as in yay. Yes.

[Committee Assistant (Temporary Clerk)]: And senator Lyons. Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: And then we'll hold both those votes for senator Morley with the expat from agriculture. And I'm actually looking for a reporter of the bill. And I think the only one who hasn't reported is senator Morley. So we'll ask him if he wrote it to and we'll maybe not have to respond to. Remember, my name offered a lot of humor to the senate over the last couple of years, John, so you're fine. Try saying people skiing. He don't skiing. That's not wrong. As

[Committee Assistant (Temporary Clerk)]: long as I hear it just before I understand it, I'm fine. So what is the official title of this bill? The official title of the bill? Yeah. An act relating to the

[Sen. Virginia "Ginny" Lyons (Chair)]: role of advanced practice registered nurses in hospital care. Yeah. So what we say APR APRN bill. Check relating to the role of APRN and and. He was always on. Yeah. That's right. We'll we'll ask him. We're gonna I don't wanna put him in a bad place. Nobody else can do it. Okay. So welcome, Senator Gulick. Good to see you. It's good to see you too on a difficult day, and I we understand that. So we did look at s two thirty nine last week, and just to get an idea, maybe you could help us understand why you're introducing it and what benefit it will offer.

[Sen. Martine Larocque Gulick (Vice Chair)]: I can absolutely do that, Senator Chittenden Buscay, for the record. As I think is no secret, I am a social worker, and I deal with mandated reporting. Thankfully, not often, but I am a mandated reporter. This bill actually, though, didn't come through my practice. It came as a recommendation from the Vermont Center for Crime and Victim Services. When they started talking about some of their concerns about current statutes, I jumped into my social work role and realized that they were absolutely perfect, that our laws around mandated reporting could really use some updates. And it was really largely to make sure that they're doing what we intended for them to do. So I would certainly recommend having the Center for Crime Victim Services in to share their concerns with the current laws and how they have actually caused harm to victims, which is certainly not what we want our mandated reporting laws to do. They are intended to keep people safe, not be harmed. Also will say that Does Jennifer told me? Yes. I also do wanna say that this bill came at sort of the last minute with the drafting deadlines. So I expect, and actually I'm coming to you today with a recommendation for a change to it, and that is that the Department or the Office of the Child Advocate be added to the list of people taking part in the task force. And they did reject a task to be added. They very much acknowledged that they are very busy and they don't want to be on every task force, but they definitely wanna be on this one. Our laws around mandated reporting really haven't been updated since the 1990s, and I think we've learned a lot since then, and we can really do some work. The reason this is coming to you as a task force and not recommendations, is I felt like with the short deadline that I had, and with the scope of changes that might be suggested, it made much more sense to give this to the experts to come back to us and tell us what needs to change. In trying to put this all together, I did speak with some people, and what really became clear is, yes, changes are needed, but those changes need to be very carefully dialed in and really would be better suited with a task force. I am very much not generally someone who wants to just make a study because they didn't have reports, but I think in this instance, this is the most prudent way forward. Okay, And so, and looking at the bill, it's a pretty broad, having to look at statutes, rules, and policies, it's a very broad request.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, you know what rules are like to go through and what policies are like to Some go of those policies may or may not be accessible. So, have you thought about trying to narrow or be more explicit about the request and avail? Because we'll take your suggestion on it. You don't have to have them off the top of your head, but it's something I think that would be helpful. Matthew Bergstein who can help us with that. I think, Matt, you can help. I also think the Department of Children and Families Child Protection people can help. Part of the reason it is incredibly broad is, again, things haven't really been updated since the '90s, I think it is important that our laws, rules, and policies, when we're doing something with this scope and this potential impact, are really working in stand alone. So, it intentionally broad, and I would suggest perhaps giving the task force more meetings and really dialing in who's on it rather than narrowing the scope. Let them decide. Yeah. Bring the group together. Yeah. All right, we could, to the extent practical, examine all of this. Yeah, obviously. And again, the makeup of the committee, I think, probably needs some tweaking. Like I said, I've already suggested an addition. Yeah. But really making sure that we have the right people who are both looking at the statutes, but also who are applying the statutes as we currently have them. One of the things that has also come up in talking to people in the field and in being someone, being a mandated reporter, is the lack of clear understanding from people who are expected to report what the rules even are. And so I also think it would be important for us to consider training requirements for our mandated reporters. And I know we do have, for the Department, child protection has a kind of click through PowerPoint, but with the complexity of mandated reporting, I really don't think that's enough. I think that some of them are, I certainly know, I used to work in the schools, and teachers are mandated reporters, And I would regularly find myself in conversations with teachers saying, oh, you have to report this, and me being like, this is poverty, not child abuse. And so I think that there we could also really look more at the robustness. And one of the things that has come up as well, particularly as we have seen more unhoused families, more people living in poverty, is making sure that our laws are protective enough and explicit enough that people are not losing custody of their children because they are poor. PPR's work. Yeah. That was, I know, that's where it always leads to. Do you see your role for child abuse in Vermont in this role? Yes, yes. Yes, okay. And I actually would be happy to share with the community, so I have to get licensed again this year, and we have requirements for CEUs, and one of the ones that I did was on nationwide law and policy around mandated reporting and best practices, and I'd be really happy to share with the committee that PowerPoint that might help guide some of this conversation. That felt, because I knew I was gonna introduce this bill, and I think it is really important, that felt like a really important thing for me to have a sense of. Can you send that to Calista? I And it will I mean, we can look at it, but obviously behind every slide is a story. So Yes. Well, and I think one of the more important the whole thing was important, but one of the more important slides I think was sort of starting, it was, and it was given by someone who holds both a mental health license and a law license, was looking at modern best practices, and that's probably, I think, the slide that would be most helpful for the committee in thinking about how to work this bill and how to set the task force forward in doing the work we want to do to make trauma informed, modern, and reporting laws different. Well, have a question. I might just be that with some of the federal cuts that we're seeing, you know, there's there's a likelihood that there would be more stress in our community and more because of some of the policies that are coming down. But also I am curious speaking of policies that you brought up to a point. I understand the rules and statutes, but policies which policies are they talking about here? Are we talking about policies in schools, policies in government agencies, and each school will not be different. Is. Really my intent was policies at our child protection agency. How are they unfolding and navigating? And I know we've all seen horrible things that have happened when these policies are not unrolled the way that they should be, both for instances where children are harmed. I mean, and instances where children are removed and perhaps shouldn't be. So there is some work to be done Yes, I know that. And I know Senator Cummings had the question that I was gonna ask. One of the things that's very striking to me is the the word reporting, and mandatory reporting has always been a difficult place. Regardless of when and how you take it off and I know it will become sort of straddled between judiciary and health care, and insurance and such there. So, but you've got a good start on the health care. And that is what it is. Like I said, when I spoke with Jennifer Coleman, it was about a week before the deadline for Bill Lee Hart And so this was rather peacefully brought together as a placeholder for the committees to do the work to make make it go forward. It's also, you know, given both of your points about the complexity and is why it's not a bill to make changes. It is a bill to create a task force. Identify where we need to make changes.

[Committee Assistant (Temporary Clerk)]: That makes sense.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. Senator Cummings. A Number of years ago, we had two children die in custody. Yes. And there was a Were you on that task force? I was. I was among the first one. I was on the cap. Right after that, yes, I had worked very hard to put in place our current Matthew Burst and our child protection. Yes. But on the last day, it's also Doug proceeds last day as commissioner. Mhmm. Had social workers come in tell us about the staffing stress that you're under. Mhmm. That you can have all the rules you want, but we didn't, during the Great Recession, apparently the whole middle level of supervisors was let go, and so these were the people that normally supervised the 20 right out of school that were doing the hands on work, and that's, I think, something that we haven't really wanted is are we adequate staffing so that we can do adequate support for patients? Is that something you want to add into the charge for the working room to evaluate the staff needs within what? Within DCF? DCF. Organizations? I will answer the question. The answer is no. We are not actively on staffing. And I, well, I know, and it's, it's, yeah, horrible, really. One of the reasons that I would recommend thinking about having this task force really to also recommend training requirements is that one of the ways that I think we can alleviate some of the pressure on that system is by lowering the number of reports that shouldn't be reported. When people don't know if they should report or not, often because of the, they report. And so there are many reports that come in that, and that clogs the system and slows down investigations on the things that should have been reported and should be investigated. So that's one of the reasons that I'm also recommending that we look at adequate training for mandated court orders. So, I mean, automatically, just sitting here, we've identified staffing and training and in addition to the crime victim services, there are probably other things in that Bernstein. So, we've got Yes, I know what needs to change. So, we have a lot of things to put into the bill. So, given where we are in session, I think, unless I hear differently from the committee, I think it's a good place to go. And, you know, if you don't wanna do it, you know, just let me know. No. I see. Question. Do we have to make all those things explicit in the bill? Or I think it's going in ended enough that the that this working group will I know that they'll look at staffing because two reasons I would put staffing. One for the group to understand support. Secondly, for the administration, others to be responsive. If you don't put it in, they're not gonna provide the data. They banged it. So, they made it. And I think finding those out explicitly makes sense to me in that you're identifying, yes, we know there's statutory changes needed, but also we may need to come back to us with recommendations about increased positions or training recommendations. So I think, do think, like I said, I left it very broad, knowing full well that it would come to this committee and it would need to change, because I was cooking the crunch. And you're also, I think, identifying the complexity of what we're dealing with and why this does need to be a task force. And again, I am rarely supportive of doing reports for reporting's sake, but I do think asking this task force to come back with recommendations on those areas is gonna be really important to rightsizing our system of child protection. And the Child Abuse and Neglect Oversight Committee that I'm working with, that massive group seems significant part of as our advocate. Really, they have to investigate, as you said earlier, they have to investigate all of these reports, some of them turn out to be important for investigators. Good. So I think we should have a conversation with Michelle Child. She's the legal advisor for us, Legis Council. Tanya, I'm going to keep you working on this with us so that we can have that happen. It'd be great. Wonderful. And once we finish here, I think probably it's going to have to at least fly by in your study for a year. I have a little bill in judiciary that I don't think it really fits. Looking at behavioral health issues and looking at the Justice Centers in Massachusetts. I guess. Okay. So looking for your help with Michelle and we'll try to come back here with some language based on the conversation here and then we'll go to the next iteration of next drug. Sounds good. No. Don't. She's got it. No, we can do it. We'll do it together. And they don't want to go overboard on this. And remember that if it's got a working group and it's got members who need per diem, it's gonna go to appropriations if they go there anywhere in Bay, so see what happens. It probably will happen to the appropriations, but most of the people that were named Avis would be in their official roles, I think that for DMs would be de minimis. The other Just put me senators on. That's pretty easy. Right. But the other question that I have actually is, this is a big group. It's a big job. We're giving them until your original date here is November 26. You might want to extend that a little bit and I'm wondering how far we might want to extend it. I don't know, we were tasked with redoing the entire education staffing system in three months. Was you. I would want to hear from the members that were tasking to do the work, how long they think they would need to do the work. I'm perfectly open to extending it. I don't want to have it sit out three years because I think it's really important for it to be done. I don't think it's a two year job. Think it's really, all these people are familiar with what the problems are, just how far down the radical they go with policies. Just don't get people during June, July, and even into September. So if you assume by the time you can coordinate everybody's dates, you're in pretty close to October, so take it from there. I was thinking that something and it's the first year, the biennium next year, January 15 seems early. So, let's think about it. Yeah, yeah. January 15 was what was in my head as a possibility because it is the first year of the biennium, and my hope, though, is to be able to do some work on changing the actual laws in the next session. There'll be time. I think it'll be time. This is good. Great. Really glad that you put the bill together, even if it was at the last minute. So, let's stay in communication, and we'll connect with, I'll have Melissa connect with Michelle. That sounds great. And if anyone on the committee has ideas of what we should be putting into the draft for purposes of discussion, then let Tanya or me or Michelle Childs. I'm happy to. I can move at ease with. Wonderful. Thank you. Perfect. Thank you. Nice work. Coming in. Yes. Of course. Give us extra work. You know? Copy, Jill. Okay. We've got seven minutes before Jen comes back in. So we're gonna take a little