Minutes

Southern Nevada District Board of Health Meeting
July 26, 2007 - 9 a.m.

Clemens Room
Southern Nevada Health District Ravenholt Center
625 Shadow Lane
Las Vegas, Nevada

Vice Chair Steven Kirk called the meeting of the Southern Nevada District Board of Health to order at 9:00 a.m. and the Pledge of Allegiance was held. He also noted that he had been provided with the Affidavits of Posting and Mailing of Agenda meeting notices, as required by Nevada’s Open Meeting Law. The Affidavits are incorporated into these Official Minutes.

Board Members Present:

Steven Kirk - Vice Chair, Councilman, Henderson
Gary Reese - Secretary, Councilman, Las Vegas
Ricki Barlow - Councilman, Las Vegas
Susan Crowley - At-Large Member, Environmental Specialist
Chris Giunchigliani - Commissioner, Clark County
Joseph Hardy, MD - At-Large Member, Physician
Tim Jones - At-Large Member, Regulated Business/Industry
Bubba Smith - Councilmember, Mesquite
Lawrence Weekly - Commissioner, Clark County
Frank Nemec, MD - At-Large Member, Physician Alternate
Stephanie Smith - Councilwoman, North Las Vegas Alternate

Absent:

Jim Christensen, MD - At-Large Member, Physician
Robert Eliason - Councilman, North Las Vegas
Mary Jo Mattocks, RN - At-Large Member, Registered Nurse
Linda Strickland - Councilmember, Boulder City
Tom Collins - Commissioner, Clark County Alternate
John Onyema, MD - At-Large Member, Physician Alternate
Steven Ross - Councilman, Las Vegas Alternate
Debra Toney, RN - At-Large Member, Registered Nurse Alternate

Executive Secretary:

Lawrence Sands, DO, MPH

Legal Counsel:

Stephen R. Minagil

Other SNHD Board of Health Members/Alternates Present:

Lon Empey - At-Large Environmental Specialist Alternate
Gerri Schroder - Councilwoman, Henderson Alternate
Jimmy Vigilante - Alternate At-Large Member, Regulated Business/Industry

Staff: Mike Walsh; Sylvia Claiborne; Glenn Savage; Dennis Campbell; Mark Bergtholdt; Bonnie Sorenson; Rory Chetelat; Mary Ellen Britt; Angus MacEachern; Patricia Rowley; Ann Markle; Jerry Boyd; Stephanie Bethel; Rick Reich; SaBrina Hagan-Finks; Jo Alexander; Veronica Morata-Nichols; Nicole Bungum; Rayleen Earney; Steve Goode; Michael Tsai; Deborah Williams; Jennifer Sizemore; Stephanie Bethel; Brian Labus; Leo Vega; Forrest Hasselbauer; Recording Secretaries: Shelli Clark and Diana Lindquist

Attendance:

Oath of Office: Dr. Sands indicated that the oath of office would be administered to new Board members being seated today. Stephen Minagil, Board Legal Counsel, administered the Oath of Office to the following elected members and alternates:

Steven Kirk – City of Henderson representative
Gary Reese – City of Las Vegas representative
Ricki Barlow – City of Las Vegas representative
Bubba Smith – City of Mesquite representative
Stephanie Smith – City of North Las Vegas alternate
Gerri Schroder – City of Henderson alternate

Members Weekly and Giunchigliani arrived at the meeting after the initial Oath was administered. Prior to the Consent Agenda, Mr. Minagil administered the Oath of Office to Chris Giunchigliani – Clark County; and Lawrence Weekly – Clark County.

Recognition:

Nutrition Challenge Program named a NACCHO Model Practice
Dr. Sands invited Rayleen Earney, health educator with the office of Chronic Disease Prevention and Health Promotion, to discuss an award received from the National Association of City and County Health Officials (NACCHO) concerning the Nutrition Challenge program.

Ms. Earney explained that the Nutrition Challenge program is a 12-week web-based program focusing on adult consumption of fruits and vegetables. Individuals with healthy diets lower their risk of developing chronic disease such as obesity, cardiovascular disease and certain types of cancer. There are 1,537 registered users for this program currently. The goal of the model practice program is twofold:

1. To nationally honor and recognize outstanding local public health practice and
2. To promote sharing of these outstanding practices among local health departments.

Twenty-nine awardees were selected out of 118 applicants. Additional information can be found at www.gethealthyclarkcounty.org. Ms. Earney shared two handouts with board members concerning healthy food choices (attachment #1). A caloric food guide was also distributed. Ms. Earney also thanked the Public Information Office for designing flyers and web pages for the Nutrition Challenge program. Dr. Sands encouraged board members to take a look at the website and recognized staff for their efforts in developing the website.

HD-tv Awards
Dr. Sands invited Jennifer Sizemore, public information manager, to brief the board relative to HD-tv (health district television). HD-tv has been broadcast for about one year; new episodes air every six weeks. We work with our partners to highlight their programs and showcase how the district works together with the community. Ms. Sizemore shared a clip which highlighted different HD-tv episodes.

Bryan Gresh, The Gresh Group, Inc., presented to the Board three awards which recognized the health district’s cable television program, HD-tv. The first award was the Award of Distinction, presented by The Communicator Awards, an international award recognizing outstanding work in the communications field; our work was judged to exceed industry standards in both production and communication skills. The second award was a bronze Telly for outstanding achievement; this year’s recipients include the Discovery Channel, the NBC television network and Walt Disney Studios and the award is designed by the company who designs both the Emmy and Oscar statues. The third award was Platinum Best of Show by the Aurora Awards. The first place honor was in the news magazine category and was scored an excellent in content, creativity and execution categories. This year’s first place winners include ESPN, National Geographic and NASA. Receiving three awards in the same year is an incredible salute to the collaborative efforts of the district and The Gresh Group. Mr. Gresh recognized two of his staff members who work to make the show a success: Sue Yurcic, writer and producer, and Kris Chaikowsky, editor, who put together the programs.

Member Giunchigliani asked if this will be updated annually, and suggested that Dr. Sands should be more featured in the program. Mr. Gresh said that one new show is run every six weeks, and are constantly updated. Mr. Gresh said that he is the anchor that does the lead in; Jennifer Sizemore and Rosanna Minnich report the stories and Stephanie Bethel will also be reporting in future episodes. The Gresh Group does the work and the district does the on screen reporting. Member Giunchigliani asked if the advertising budget was broken out separately for the program. HDtv is done on a separate contract. The lobbying contract is also separate.

Member Stephanie Smith said that when she first joined the Board, the heath district was under the radar. To generate awareness of the important public health function, board meetings were televised. It’s very important what the district does, and she congratulated staff for the program and getting the word out. She said it is important and money well spent.

I. Consent Agenda: These are matters considered to be routine by the Southern Nevada District Board of Health and may be enacted by one motion. Any item, however, may be discussed separately per Board Member request before action. Any exceptions to the Consent Agenda must be stated prior to approval.

1. Approve Minutes / Board of Health Meeting: 6/28/07
2. Approve Payroll / Overtime for Periods: 6/02/07 – 6/15/07; 6/16/07 – 6/29/07
3. Approve Accounts Payable Registers: #1081: 6/08/07 – 6/14/07; #1082: 6/15/07 – 6/20/07; #1083: 6/21/07 – 6/27/07; #1084: 6/28/07 – 7/04/07
4. Election of Southern Nevada District Board of Health Officers for FY 2007-08: Chair – Steven Kirk; Vice Chair – Chris Giunchigliani; Secretary – Gary Reese
5. Petition #14-07:  Approval to Extend the Lease Agreement for Health District Offices Located at 400 Shadow Lane
6. Petition #29-07: Approval of Amendment Number 3 to Interlocal Contract with Clark County on Behalf of Clark County Social Service for Funding to Provide Ryan White Part A Services (formerly Ryan White Title I Services)
7. Petition #26-07: Approval of Revised Classification Specification for Accounting Technician I/II, Recommended Schedule 14 ($35,350 - $49,331) / Schedule 16 ($39,164 - $54,633)
8. Petition #31-07: Approval of New Classification Specifications for Purchasing Agent, Recommended Schedule 23 ($55,974 - $78,081) and Accounting Supervisor, Recommended Schedule 26 (65,280 - $91,087)

A motion was made by Member Smith to approve all consent items; seconded by Member Reese and was unanimously approved.

Oath of Office:
Dr. Sands said that the Oath of Office would be administered to the new officers. Stephen Minagil, Board Legal Counsel, administered to Oath of Office to the new Board of Health Officers for FY 2007-08:

Steven Kirk – Chair
Chris Giunchigliani – Vice Chair
Gary Reese – Secretary

II. Public Hearing / Action

1. Memorandum #10-07: Application for Approval for a Lateral Expansion to Nevada Power Company Class III Landfill (Permit Number LF006-CMF-01) at Reid Gardner Power Station, 501 Wally Kay Way, P.O. Box 279, Moapa, NV 89025. Petitioner: Nevada Power Company, Richard Willer and Dave Phillips, Nevada Power Company Representatives.
   
   Chair Kirk declared the public hearing open.
   
   Member Reese disclosed that his daughter works for Nevada Power Company. He has not spoken with her regarding the application; but he feels that he can participate in discussion and vote on the matter.
   
   Member Stephanie Smith stated that she is a Nevada Power customer but that would not affect her decision.
   
   Dennis Campbell, environmental health manager with solid waste and compliance, brought forward an application for approval for a lateral expansion to Nevada Power Company’s Class III landfill at the Reid Gardner power station. The landfill will be expanded from 112 acres to 120 acres at its current location. Nevada Power Company has met all requirements for a lateral expansion at their current location in Moapa as stipulated in the solid waste management authority regulations governing solid waste management and Nevada Administrative Code (NAC) 444.733.1 through 444.733.9. Staff recommends Nevada Power Company be granted a permit to expand the landfill with conditions outlined in the memorandum. Mr. Richard Willer from Nevada Power was present to answer questions.
   
   Member Giunchigliani stated that on page 3 of the document, the Nevada band of Paiutes opposed the lateral expansion with issues of the fly ash. Mr. Campbell said the epidemiology office determined that this lateral expansion would not have any impact as there are no air quality issues; this is an existing facility and there are air monitoring stations around the site currently. Member Giunchigliani asked if the district responds to letters of opposition; she said that we need to communicate that their opposition was noted and the concerns were taken into consideration.
   
   Member Crowley asked about the original landfill and if issues arose that would cause hesitation in expansion, such as ground water impacts. Mr. Campbell said his staff inspects the facility twice annually and there are no concerns with the existing landfill.
   
   Member Hardy said asked with the pressure to build homes and developments in that area if there has been communication with planning at the county and local jurisdictions on those issues for the future. Mr. Campbell said that information and approval is obtained from Clark County zoning and planning offices before an application is brought to the Board for approval.
   
   Member Stephanie Smith asked why Nevada Power has a landfill. Mr. Willer said that power is generated with coal, which is burned inefficiently such that coal remains in the residual solids and fly ash. There needs to be a place for disposal, and approval was received to have a site adjacent to the Reid Gardner facility. Member Smith asked if there were more efficient ways to burn the coal so that a landfill would not be necessary, such as a second burn. Mr. Willer responded that they are working under an order from air monitoring to make improvements in combustion. Member Smith expressed concern about the effects on both the air and the ground. Mr. Willer said that fly ash is an inert product and has been used as fill at Lone Mountain.
   
   Member Bubba Smith referred to page 3 where it was cited that it was not the dump site that affected the respiratory systems. There is a report showing that 200 people have been affected with respiratory problems. He asked if the district has done anything to determine what is causing the illness.
   
   Dr. Sands said that there are a couple of issues regarding these questions. The letter addressed to the Bureau of Land Management (BLM) was in response to Nevada Power Company’s application to build new evaporation ponds and the acquisition of new land for that project. BLM will need to do an environmental health assessment that also includes consideration of potential health impacts. It is difficult to investigate the type of complaints received, primarily because the district must be invited onto reservation land. It would also take a great amount of resources to investigate as it is a small population, so to show differences a larger population is needed over an extended period of time. The other issue is the information received regarding respiratory illnesses are very common primary care complaints; it was not clear if the illnesses were reported over a period of years, so this would not be unexpected. More information is needed to correlate the complaints. Environmental health verified with the Clark County Department of Air Quality and the Nevada Department of Environmental Protection (NDEP) that there is no indication that air quality has been compromised. This application will maintain the status quo for a period of time until those additional evaporation ponds are approved and put in place.
   
   Member Hardy suggested that in our response letter to the Paiute nation, we could mention that we are willing to come to the reservation upon invitation to further investigate their concerns.
   
   Member Weekly also asked that Clark County receive a copy of the response letter to the Paiute nation due to the business licensing aspect and enforcing any specified conditions. He referenced condition #4 and asked if evaporation ponds are currently on site and how many more are needed for the expansion. Mr. Willer said that approval was received previously to construct an evaporation pond atop the landfill where the scrubber blown down was paved and there are currently no baghouses. The water coming from the scrubbers contains a great deal of ash. With the last lateral expansion, they planned to build ponds on top of the base line approved by the NDEP to pump the scrubber water up and decant the water back to the evaporation ponds, leaving the ash permanently in the landfill. The current application conceives doing same process, with two additional ponds involved. This is the concept of the current landfill and they are seeking permission to continue this current concept on this lateral expansion. Proper permits will be obtained from NDEP for ponds needing to be constructed.
   
   Member Weekly expressed concern about the amount of water collected in the ponds and inquired as to how much water is used. Mr. Willer said that the existing pond is about eight acres and is approximately twelve feet deep; there is almost 100 acre-feet of water. As a result, in the permitting process state engineers gave safety permits as required and will be applied for because they have a rule regarding pools over twenty feet tall or containing more than 20 acre-feet of water require a safety permit.
   
   Chair Kirk said that we need to be concerned about the health of the Paiutes, particularly when there are letters stating that 50% of residents are experiencing some sort of respiratory condition. With the daily exposure to fly ash, he said that we need to look into situation and ensure that we are being as safe as we can.
   
   Member Jones asked if the reservation is under the jurisdiction of the health district. Dr. Sands said that it is within the county borders, however it is a sovereign nation; in order to enter the land for investigations, an invitation must be made. Member Jones asked if resources at the reservation are part of the standard plan. Dr. Sands said that we would need to look at this.
   
   Member Giunchigliani said that proof of land use approval was required and obtained from Clark County. However in reference to page 31, it said that since many of the health concerns expressed were respiratory in nature involvement with Clark County Department of Air Quality and Management was recommended. She asked if this had been initiated, if they have been contacted or if this would be part of our follow-up to the Paiute. Dr. Sands said we recommended to the BLM to contact the Clark County Department of Air Quality for that information as we have no jurisdiction over air quality. Member Giunchigliani asked that Clark County be copied on any correspondence related to this issue for monitoring to have a handle on what is going on.
   
   Mr. Willer said that Nevada Power has an air quality permit for landfill and an inspection was done recently. They are in compliance with air quality. Member Giunchigliani said if access were obtained, perhaps air quality could work with the Paiute nation and see if monitoring can occur.
   
   Glenn Savage said that the district has worked with Nevada Power in the past. The Paiute tribe has made similar complaints in the past; we made contact with them and tried to obtain personal information to initiate investigations, but we could not obtain the information necessary. In working with air quality, there was concern about wind direction and the fly ash going into the reservation area and monitoring stations were operational at that time between the landfill and the residence.
   
   Member Giunchigliani was appreciative of this information. Part of the responsibility will fall to the Paiute nation, and perhaps they will see that the district has taken an interest and are asking them to help us participate in ascertaining what is causing the illnesses.
   
   Chair Kirk asked if any member of the public wished to speak concerning this item. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Reese to accept staff’s recommendation for approval with all conditions, and incorporate all questions and answers on this item to be put in writing, and that the district follow up with the Paiute nation in writing; seconded by Member Giunchigliani and was unanimously approved.
   
   
2. Memorandum #16-07: Application for Approval for Republic Services of Southern Nevada to operate a Materials Recycling Facility located at 333 W. Gowen Road, North Las Vegas, Nevada; Permit No. MRF03-XXX-01
   
   Chair Kirk declared the public hearing open.
   
   Dennis Campbell, environmental health supervisor of solid waste and compliance, said that Republic Services of Southern Nevada have submitted an application to operate a materials recovery facility. Republic Services has met all requirements as outlined as specified in Materials Recovery Facility (MRF) regulations. Staff recommends approval of the application to operate a MRF with the conditions as outlined. Recommendation #2 on page 3 refer to the regulations which state that only 3,000 cubic yards can be stored in a facility at one time, unless otherwise approved by the Solid Waste Management Authority. In this case, staff recommends that the amount of solid waste stored on the facility be increased to 5,000 cubic yards: 3,000 yards would be solid waste and 2,000 cubic yards would be processed recyclable materials. This would provide the opportunity to move the materials off site. Alan Gaddy from Republic Services was available for questions.
   
   Member Stephanie Smith asked about recommendation #3 which stated that a business license must be obtained in Clark County and not North Las Vegas. Mr. Gaddy said that a business license was obtained in North Las Vegas. Mr. Campbell said that this was an error on the memorandum. “Clark County” should read “North Las Vegas.”
   
   Member Bubba Smith asked if 3,000 yards were still the minimum and 5,000 yards would be the maximum. Mr. Campbell said that recyclable materials are still considered solid waste until removed from the site. In order to facilitate operation of this facility, they allowed the facility to increase volume of total solid waste being stored from 3,000 to 5,000 cubic yards; the additional 2,000 yards will be processed materials ready to be shipped out to other locations.
   
   Member Giunchigliani said that item #3 said that the application was pending a land use permit; however a previous application said that the permit had been received. She asked why we were doing this differently. Mr. Gaddy said that the land use permit had been obtained. Mr. Campbell stated that the permit must be maintained, recommendation #3 must be included. She stated that with the low percentage of recycling in Clark County, in order to increase this rate we should allow them to transport the materials to the site and sort it there. She asked if modifications will be necessary to the county and cities’ definitions of facilities to allow for recycling materials to be picked up and sorted at a different site.
   
   Chair Kirk said site separation has been an item of discussion for some time in relation to MRFs. Mr. Campbell said they can sort materials at a MRF; however if it is strictly a recycling center, materials must be sorted before brought to the facility. A MRF can sort materials, which may include solid waste, and put it in different streams for different items. Member Giunchigliani ask that we start exploring updating our policies to promote better recycling throughout the county. She asked staff to bring back recommendations as a future agenda item. Mr. Campbell said that his staff is looking at all solid waste regulations and bringing them current and consistent with current practice. He also said that staff will also go to the county and various jurisdictions to make sure they understand our definition of MRFs, transfer stations and recycling centers and to ensure consistency with codes and ordinances.
   
   Member Giunchigliani expressed concern that apartment and condominium complexes did not provide space for recycling. She has asked the County to take a look at this and suggested that the cities do the same so that we are not doing anything to discourage recycling efforts.
   
   Member Hardy asked if there would be any adverse affect on others doing separation or similar opportunities. He would like to keep a level playing field among all recycling/recovery facilities. Mr. Gaddy said that recent regulations changes allows facilities to take materials back to a main facility, sort the materials and determine what is recyclable; those MRF regulations were recently adopted. Republic reviewed their operations, and have been doing essentially the same thing since 1991 as the first recycling facility in Clark County. The regulations as adopted pointed out that Republic tries to maximize their recycling efforts and they take solid waste from different areas in the county. Today Republic is asking for approval to function as a MRF, which they have been doing all along. Member Hardy said a new law allows the university system to do research on recycling.
   
   Member Jones asked to clarify that a MRF can both pick up materials and sort at the MRF, which is what is currently be done at the facility.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Giunchigliani to approve the recommendation as presented with the conditions outlined, but in item #3 replacing “Clark County” with “North Las Vegas;” seconded by Member Smith and was unanimously approved.
   
   Mr. Gaddy expressed his appreciation to staff for their assistance with the regulations and welcomed the new Board members.
   
   
3. Memorandum #20-07: Request for Approval of Renewal of Authorization of University Medical Center as a Level I Trauma Center
   
   Chair Kirk declared the public hearing open.
   
   Mary Ellen Britt, regional trauma coordinator, said that NRS 450B.237 and the Southern Nevada Health District Trauma Regulations require that any hospital seeking designation by the Nevada State Health Division as a Center for the Treatment of Trauma first seek authorization from the Board to move forward in that process. University Medical Center (UMC) submitted an application requesting authorization to continue to operate as a Level I trauma center as they have since 1999. Beginning in 1989, UMC operated as a Level II trauma center. The application was received by staff, and presented to the Regional Trauma Advisory Board (RTAB), and was unanimously endorsed. Staff recommends approval of the application. Dr. John Fildes, medical director for trauma, was present to answer questions.
   
   Member Nemec asked about the impact Sunrise Hospital’s trauma center had on UMC in regard to volume and the ability to staff with sub-specialist physicians. Ms. Britt said that since Sunrise opened their trauma center in February 2005, there have been 16,110 transports to the three trauma centers: UMC received 76% of the transports; Sunrise received 17% of the transports; St. Rose-Siena received 7% of the transports.
   
   Dr. Fildes addressed the Board regarding the impact to his program. He said that since the new centers came on line there has been no growth statistically. Redistribution has flattened out the patient volume characteristically at UMC. They have been able to support sub-specialty surgical care to existing practitioners, some of which are taxed by covering multiple centers. There has been a drop in pediatric trauma patients at UMC.
   
   Member Giunchigliani said that competition is healthy, but she expressed concern about the low patient volume at the other trauma centers and taxing specialists who are covering multiple facilities. She asked if a review process exists to reevaluate having multiple trauma centers. Ms. Britt explained that one benefit of having three trauma centers is to relieve the burden when one center may become overwhelmed. The RTAB is working to develop an inclusive system where we can allow for redundancy and the necessary resources in place. Dr. Fildes said that they have been careful with acquiring new staff or continuing staff from all ranks so that the program is the right size and staff to patient ratio is correct. The volume curve is very flat. Following the initial 24% drop in trauma patients, the center is functioning well and has stabilized at that level.
   
   Member Giunchigliani asked if there is a diversion issue in the trauma centers such that insured patients go to the other centers. Ms. Britt said that trauma field triage protocol determines trauma transport based on catchment areas. Any EMS transport within UMC catchment area goes to UMC, regardless of their ability to pay. This holds true for all trauma centers. There is a trauma overload mechanism in place, or internal disaster, where if any trauma center reaches capacity and are unable to take additional trauma patients the center is allowed to declare that status, which has happened three times in the last year. Each case is reviewed to ensure the declared overload was appropriate and that the center was in compliance with their own internal policies and the trauma plan. To date there have been no issues.
   
   Member Giunchigliani asked if the merger of MedicWest and American Medical Response caused any impact on trauma or delivery of service. Ms. Britt replied that there should not be any changes.
   
   Member Bubba Smith asked to clarify the difference between functioning as a Level II and a Level I trauma center. Ms. Britt explained that prior to 1999 UMC functioned as a Level II trauma center. Level I is the highest level of trauma center and the most complex. Member Smith expressed concern about the vast differences in percentages of trauma patients at the three trauma centers. He asked if the triage protocols determine where the patients are transported. Ms. Britt said that the catchment area determines patient transport; as UMC is a Level I trauma center it has the largest catchment area and has all required clinical specialties. Sunrise has a small catchment area and serves as a Level II trauma center. The catchment area for St. Rose-Siena serves mainly Henderson and fairly stable trauma patients. St. Rose-Siena is a Level III trauma center.
   
   Member Jones asked if a third-party, such as the American College of Surgeons (ACS), is part of evaluation process, including determining the catchment area based on the population to be served. Ms. Britt responded that the catchment area is created by the RTAB and is part of the trauma plan and is included in the triage protocol. ACS verifies the centers based on the levels of trauma for the clinical and administrative needs and to asses their ability to be a trauma center. Mr. Jones asked if academic research is part of being a Level I trauma center that may not occur in a small catchment area. Ms. Britt replied that that particular issue was not part of the thought process; designating Sunrise as a Level II trauma center in the beginning allowed the opportunity for maturity. Member Jones disclosed that his wife is the Bureau Chief for Licensure and Certification and will play a part in the decision process later on; he felt that this would not affect his decision.
   
   Dr. Sands said that regional trauma plan developed was done in accordance with guidance from ACS. Ms. Britt said that there is a volume performance requirement for Level I centers. When additional trauma centers are considered, there cannot be too much volume removed from UMC and possibly destabilize their program. The RTAB reviews the data on a monthly basis and the medical audit committee reviews the care provided. A mechanism is in place to assess how each center performs and they work collectively as a system. Dr. Fildes said that in general size and volume there are small Level I centers in other areas. Member Nemec asked with Sunrise and St. Rose-Siena coming online if a change in pay status or volume shifts was noted.
   
   Dr. Fildes replied that initially there was a volume shift in the total number of patients seen. The proportion of pediatric patients accounted for the most significant drop. The demographic in terms of payor status has remained the same. The other centers are receiving an equivalent mix.
   
   Member Nemec asked if this data was available to verify that centers in more affluent areas are receiving more of the patients with ability to pay. Dr. Fildes said that the numbers are stable. Member Nemec asked about data for the other facilities. Ms. Britt said that the information can be requested. Member Nemec expressed concern about the economic impact on UMC and the resultant drain on property taxes affecting Clark County residents.
   
   Chair Kirk said that the responsibility as members of this Board is for the health and welfare of all the members residing in their respective jurisdictions. The plan is for the outlying hospitals to come on board as Level III trauma centers; the closer to the urban core the centers would be Level II, and UMC would be the Level I center. He said that he would like to see trauma centers developed in North Las Vegas and other areas to have a geographically balanced trauma system. Ms. Britt said that when an initial assessment was completed, the payor mix in the Sunrise catchment area mirrored what was occurring with UMC. She said that this issue can be revisited. Chair Kirk said that this information is important and the Board would like to see this data.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Giunchigliani to approve the application as submitted and directed the RTAB to look at collecting data regarding payor status; seconded by Member Hardy and was unanimously approved.
   
   
4. Memorandum #21-07: Request for Approval of Renewal of Authorization of St. Rose Dominican Hospital as a Level III Trauma Center
   
   Chair Kirk declared the public hearing open.
   
   Mary Ellen Britt, regional trauma coordinator, said that for the same reasons as University Medical Center, St. Rose Siena submitted an application for authorization to continue operating as a Level III trauma center, which they have done since August 2005. Staff and the RTAB unanimously endorse this application and recommend approval based on their willingness to provide trauma services to the community, their active participation in the trauma system and their compliance with the trauma regulations. Kim Dokken, trauma program manager, was present to answer questions from the Board.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Nemec to approve the application as submitted; seconded by Member Stephanie Smith and was unanimously approved.
   
   
5. Variance Request to Operate a Child Care Facility not in Compliance with the District Board of Health Regulations Governing the Sanitation of Child Care Facilities (APN 163-19-511-011). Petitioner: LVC Acquisition Corporation, dba Las Vegas Athletic Club, 4250 Grand Canyon, Las Vegas, Nevada, (existing Health permit #21625-HGV-04), Chad O. Smith, Director for Andrew J. Palluck, President
   
   Chair Kirk declared the public hearing open.
   
   Mark Bergtholdt, environmental health supervisor, said that Las Vegas Athletic Club desires to operate a facility with fewer toilets than required by current regulations. They propose to use only children two years and older as their count to determine the number of child high toilets and lavatories for their facility. Children under the age of two will not be included in this count. Staff believes that granting the variance will not threaten the public health and safety if the conditions recommended in the variance are met, which include:
   
   1. Number of lavatories be calculated using child care licensing jurisdiction capacity of children two years old or more to determine the number of toilets or lavatories. The formula to arrive at the number would come from SNHD Regulations 8.7.5 and 8.7.11. The capacity of children under the age of two would be excluded from the formula.
   
   2. One diaper changing surface for ten non-toiled trained infants or children be installed with one adult high lavatory installed adjacent to every two diaper changing surfaces.
   
   3. A sign indicating the maximum number of children broken down into toilet trained and non-toilet trained be displayed at the front counter of the facility.
   
   4. Additional appropriate fixtures are to be installed if the ratio of non-toileted trained children to toilet trained children changes from the ratio of 1:5.
   
   Melissa Peters from Las Vegas Athletic Club was present to answer questions. Chair Kirk asked if she agreed with recommendations. She replied in the affirmative.
   
   Member Hardy asked if the health regulations addressed cloth diapers. Mr. Bergtholdt indicated the regulations do address cloth diapers. Member Hardy asked if the diaper changing station with the toilet was used to rinse the diaper and if not, how one would rinse the diaper. Mr. Bergtholdt said that there are special requirements in the regulations for handling cloth diapers that need to be followed; rinsing of diapers is prohibited by the regulations.
   
   Member Jones asked if there is a history and experience as to the ratio of children attending the centers and if it is stable. Ms. Peters said that this ratio currently exists at two of their locations and a reservation system is used. Member Jones asked if children have been turned away due to the ratio. Ms. Peters said that this has occurred and parents can drop-in in the event there is a cancellation; however they may be asked to leave if there is not enough room.
   
   Member Giunchigliani commended Ms. Peters for using a reservation system and said it was an excellent idea.
   
   Chair Kirk asked if anyone from the public wished to speak to this matter. No one came forward to speak and Chair Kirk closed the public hearing.
   
   A motion was made by Member Stephanie Smith to approve the variance with the conditions as outlined; seconded by Member Giunchigliani and was unanimously approved.
   

III. Report / Discussion / Action

1. Petition #30-07: Approval to Seek Funding Sources for the New Main Campus Building
   
   Mike Walsh, director of administration, informed the Board that he along with Dr. Sands and Jeff Gerber from PGAL, made a presentation to the Clark County Board of Commissioners at their July 3rd meeting. As result the presentation and questions asked, the question of other entities participating in funding was raised. Based on that recommendation, and the support of Members Weekly and Giunchigliani, the district is asking for the Board’s guidance in approaching the different municipalities, either the city managers or councils, to present the plan and possibly ask for their assistance in funding the facility.
   
   Member Hardy suggesting changing the name of the agency back to the Clark County Health District.
   
   Member Stephanie Smith said that she lives in North Las Vegas, but also Clark County, and she pays Clark County taxes for these types of matters. She said that the county receives their money for these issues through the property taxes.
   
   Member Weekly said that he supports staff on this issue. He was not happy with the presentation at the Commission meeting and the presentation was disappointing to his fellow commissioners hearing the plan for the first time. He suggested briefing council members before making a presentation. The commission would have liked a briefing prior to the presentation. The county is in agreement that the other jurisdictions should participate in funding the building. From a local government stand point, all jurisdictions should be involved. He said that a new facility and an expansion are very important. He feels that the local government is not taking this very seriously – it is more than just seeking a nice facility. It is about having the adequate space needed in order to put these services out to public. In types of emergency, the district is often a first responder, such as in time of a pandemic. He said that when the briefings and presentations occur, we need to say what we are asking for and what exactly is needed.
   
   Mr. Walsh said that the district was the last item on the agenda and county staff asked him to shorten the presentation because the meeting was running late. Member Weekly said that this item was just as important as the items previously heard. The literature needs to be delivered in advance to staff, and personal appointments should be made.
   
   Dr. Sands said that this was a lesson learned and it will not happen again. Arrangements have been made with Darryl Martin’s office to meet with the commissioners for a more detailed briefing. This item today was also agendized as an action item if the Board chooses to direct staff as to how to engage the other jurisdictions in this discussion and to share what our plan is at this point.
   
   Member Barlow said that everyone understands and agrees that the health district needs to be expanded due to age and capacity of the existing building. He asked if the various municipalities will need to put forth dollars to build a new building as well as operational expenses. Mr. Walsh confirmed that this would be just to fund the building.
   
   Member Giunchigliani said that the possibility of discussion for direction is needed. New members need to know what the plan is and see pictures of this building. They are not aware that the Wellness Center will also be part of a new facility. She suggested inviting members of the jurisdictions to tour the existing facility or see photos. She strongly encouraged having briefings beforehand. She commended the architect for doing an excellent job of bringing the new building in at a good cost per square foot. This lends to a good argument. She also suggested having staff brief the staff at the jurisdictions. She said that majority of the funding should come from the county. We should be more inviting of the jurisdictions and include them in discussions. Following this, the financial directors could meet with Mike and discuss the cost of the building, and have further discussion.
   
   Chair Kirk agreed that each council member of the local entities should be briefed in detail. Member Weekly said that even though each jurisdiction has representation on the Board, they each sit on many other boards as well. Other council and commission members are not aware of what is going on and feel frustrated. He asked that the district keep the jurisdictions informed.
   
   Member Hardy said that this opens a new aspect of revenue sharing. He is looking at the reality that in an open meeting the discussion be done not just in this forum, but with the Southern Nevada Planning Coalition and those kinds of things where discussion is held to develop a philosophy and process to determine how to meet and work together. He said that the public needs to have comment on the matter as well.
   
   Member Giunchigliani said there have been two meetings on the facility already. However, once the various entities are briefed, a meeting should be held where the public can provide comment and hold a public hearing. The public needs to be aware that the building is needed and why.
   
   Member Jones asked if public funding was the only acceptable venue, or if sponsorships and private input could be considered. Mr. Walsh said that this has not been investigated but staff could do this as well. He said that one funding alternative discussed by George Stevens at the commission meeting had to do with the issuance of bonds. As ¼ cent of the property tax revenue allocated to the district are designated for capital, that dollar amount will increase annually. Over the life of the bond, we could pay for the building, and reimburse the county for money paid up front, which would be approximately $4.5 million.
   
   Member Bubba Smith said that most revenues from the cities do go to the county. He asked staff to come to Mesquite and brief city officials. He expressed concern about the lease agreement, and agrees that a new building is necessary. He said that the mayor authorized him to state that office space can be provided for the district to have a presence at least once a week in Mesquite. Mr. Walsh said that cost savings from leases would go back into paying for a building.
   
   A motion was made by Member Giunchigliani to move forward with the development of the building and locate financing, that staff should brief the various councils and commissions, offer tours and such, involve staff and work with the financial groups and come back to the Board with an “A” and “B” process, to include a public hearing venue; seconded by Member Weekly and was unanimously approved.
   
   Member Giunchigliani said that when exploring different options, because bonding could be a payback position, the entities should be aware of this as well.
   

IV. Citizen Participation: Citizen participation is a period devoted to comments by the general public about matters relevant to the Board's jurisdiction. Items raised under this portion of the Agenda cannot be acted upon by the Board of Health until the notice provisions of Nevada's Open Meeting Law have been complied with. Therefore, no vote may be taken on a matter not listed on the posted agenda and any action on such items will have to be considered at a subsequent meeting.

Chair Kirk invited any individuals wishing to address the Board on matters under their jurisdiction and wishing to speak to come forward. No one came forward and the citizen participation portion of the meeting was closed.

V. Health Officer & Staff Reports

Orientation Booklet
Dr. Sands directed Board members to the orientation booklet. He hopes that board members find the information useful as it discusses the health district, the role of the Board, and public health in general. If members would like to set up an orientation session with staff, please let Shelli Clark know and staff can meet individually or in groups.

All board members also should have received by email or with their board materials a survey for the time and date for regular board meetings that will accommodate most members. He asked that the information be submitted to Shelli Clark before the end of the month so that the information can be compiled and prepared for discussion at the August meeting.

Legislative Update
Dr. Sands invited SNHD lobbyists Bryan Gresh and Gary Milliken to brief the Board relative to items of interest to the district during the 2007 legislative session.

Mr. Gresh said that there were at least three dozen pieces of legislation required the district’s involvement. In the 2005 session much time was spent keeping the district intact; a dedicated funding stream and keeping the chief health officer position whole was accomplished. In the 2007 session local government were hot topics. State funding remains tight and a large point of discussion was funding the state’s highway shortfall. Local governments diverted local property tax dollars. The dedicated funding streamed remains locked in at its current rate.

• Assembly Chad Christenson asked that the health district be included as part of this Assembly Concurrent Resolution 25 which urged Nevadans to be prepared in case of disaster. The assemblyman was impressed with the Can-it campaign and invited the district to be recognized on the floor of the Assembly and Senate.
  
  
• AB 410 establishes an immunization registry in the state of Nevada, as sponsored by Assemblywoman Sheila Leslie to assist in improving Nevada’s immunization rates. The bill establishes a mandatory immunization registry and requires the State Board of Health to oversee it; the second provision creates incentives so more organizations will perform immunizations.
  
  
• SB 266 allows for rapid HIV testing of pregnant women and their unborn children. Mary Ellen Harrell, public health nurse manager, summed up the need for this bill in one statement: “Recently in our clinic we treated a mother and her child; the mother had unknowingly been infected by her husband. She gave birth without being tested and had been breastfeeding her child prior to learning of her positive HIV status. The risk of transmission to the child could have virtually eliminated had the mother been tested while pregnant.” The bill did pass.
  
  
• AB 629 created funds for worthy causes and issues important to the district. $500,000 is allocated to the development of an outreach plan to assist the uninsured in enrolling in health insurance programs; $250,000 is allocated to the establishment of a coordinator of vascular health position; $300,000 will provide for grants to volunteer organizations that provide emergency medical services in the state for training and equipment. The popular three-square program received $1 million for the construction of a food production facility.
  
  
• Language was inserted in SB 106 to include the district on the short list of those allowed to inspect certain confidential or restricted documents related to potential acts of terrorism. If the district is one that will respond to a disaster, and the chief health officer has designated the employees as having an operational need to know.
  
  
• SB 123, the public records bill, was modified to ensure the language was acceptable to the district.
  
  
• Mr. Gresh and Mr. Milliken were asked to get legislative attention focused on childhood lead poisoning. Working with Assemblywoman Susan Gerhardt, a resolution was signed by Barbara Buckley recognizing our childhood lead poisoning prevention program and our collaboration with and funding from CDC.
  
  
• SB 199 provided funds for poison control for an additional two years to maintain the poison control call center.
  
  
• SB 244 concerns response time and wait times in emergency rooms. A bill was passed in 2005 that did not work for many different reasons. The health district is very involved in this issue. When an ambulance arrives at a hospital, the time is logged and when the patient is accepted by the hospital, the time again is logged; anything over 30 minutes requires explanation. The purpose of this bill is to see which hospitals are meeting the 30 minute criteria and why certain hospitals are not. There will be quarterly meetings where this information will be made public. The hope is to have all hospitals accept patients within 30 minutes.

Member Giunchigliani asked if a definition were determined for “received into the hospital.” Mr. Milliken said that this is the conflict with the hospitals currently. The hospital must be physically in control of the patient. She asked if there were funding or an impact on the district for the immunization registry. Mr. Gresh said that there is no funding; however our current registry will work with the state-wide registry. The goal is to interface the two systems. Dr. Sands said that separate from that bill, there is a funding line in the state health division budget which allows for hiring of staff to work with the registry. There are continuing discussions about grant money for these positions. No adjustments are necessary to our budget at this time.

Member Giunchigliani asked if there is a process for the Board for determining legislation. The district does not get bill drafts. She asked how we determine what position the health district takes and if the Board gives guidance. Dr. Sands said his office coordinates with the public information office and our lobbyists. Member Giunchigliani said that she felt the Board should be involved in the process. Mr. Milliken said that he and Mr. Gresh work closely with the District prior to the session; however once the session is in progress it is difficult to meet with a large number of people. Mr. Gresh said that if there is something specific needed, they have teamed with an entity or specific offices and obtain a bill draft from someone they have worked with previously.

Member Giunchigliani said that in the future she would like the Board to be more involved, what the procedures will be, and what input the Board can provide. She would like to know the position of the district.

Member Stephanie Smith said in North Las Vegas they have a legislative committee that presents to the council specific information. Mr. Milliken said that he and Mr. Gresh review all the BDRs and when something appears that might affect the district, staff is contacted to discuss how to proceed. Mr. Gresh said that we have a good relationship with both Washoe County District Health Department and the State Health Division, and collaborative efforts take place to ensure that the best interest of all parties is considered.

Member Hardy said that another piece of legislation regarding drug discount cards for prescriptions. The county has the opportunity to have a free discount card to save approximately 20% on prescriptions.

Member Barlow addressed agenda item Section 6, item 3a which lists the term of office for representatives from the City of Las Vegas. He said that it should read “June 30, 2009” as opposed to “June 30, 2000.”

Temporary/Itinerant Food Permit Fees
Glenn Savage said that at the last Board meeting, there was discussion about annual permits for high risk food vendors. That afternoon he received an email from Julie Tracy, and it became a talking paper among staff. She raised some very good issues which staff is considering, which include:

1. the fee should be higher than those with low-risk foods;
2. it should be necessary to have a commissary to store food and work from;
3. all equipment must be approved;
4. there must be hand washing stations available;
5. all employees need to have a health card;
6. all menu items need to be presented for staff to compare operations with actual equipment;
7. the process should be limited to vendors within Clark County versus those vendors coming from out-of-state.

Staff continues to discuss this issue with Ms. Tracy and other vendors.

VI. Informational Items - Duly Noted

VII. Adjournment

There being no further business to come before the Board, Chair Kirk adjourned the meeting at 10:50 a.m.

SUBMITTED FOR BOARD APPROVAL

Lawrence Sands, DO, MPH, Chief Health Officer
Executive Secretary

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