Board Meeting Minutes - May 2011 - Southern Nevada District Board of Health

Southern Nevada District Board of Health Meeting
May 26, 2011 - 8:30 a.m.

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

Vice Chair Jones called the meeting of the Southern Nevada District Board of Health to order at 8:30 a.m. and led the Pledge of Allegiance. Annette Bradley, Esq., Legal Counsel confirmed the meeting had been noticed in accordance with Nevada’s Open Meeting Law.

Vice Chair Jones noted a quorum of was present at the start of the meeting with Members Anthony, Chandler, Christensen, Gustaveson, Menzel, Onyema, Vigilante and Wood seated.

Vice Chair Jones reminded Board members and attendees that the meeting is being recorded and webcast to staff; he asked all in attendance to turn off all cell phones and electronic devices as they interfere with the sound system, which in turn affects transcription of the meeting and the webcast.

Board Members Present:

Tim Jones — Vice Chair, At-Large Member, Regulated Business/Industry
Stavros Anthony — Councilman, Las Vegas
Travis Chandler — Councilmember, Boulder City Alternate
Jim Christensen, MD — At-Large Member, Physician
Karl Gustaveson — Councilman, Mesquite Alternate
Nancy Menzel, RN — At-Large Member, Registered Nurse
John Onyema, MD — At-Large Member, Physician
Mary Beth Scow — Commissioner, Clark County
Jimmy Vigilante — At-Large Member, Environmental Specialist
Anita Wood — Councilwoman, North Las Vegas Alternate

Absent:

Linda Strickland — Chair, Councilmember, Boulder City
Kathleen Boutin — Councilwoman, Henderson
Robert Eliason — Councilman, North Las Vegas
Chris Giunchigliani — Commissioner, Clark County
Lois Tarkanian — Councilwoman, Las Vegas

Executive Secretary:

Lawrence Sands, DO, MPH

Legal Counsel:

Annette L. Bradley, Esq.
Terry Coffing, Esq. — Marquis & Aurbach

Other SNHD Board of Health Members/Alternates Present:

Michael Collins, RN — Alternate At-Large Member, Registered Nurse

Other SNHD Board of Health Members/Alternates Not Present:

Kam Brian — Alternate At-Large Member, Environmental Specialist
Susan Crowley — Alternate At-Large Member, Environmental Specialist
Joseph Hardy, MD — Alternate At-Large Member, Physician
Debra March — Councilwoman, Henderson Alternate
Frank Nemec, MD — Alternate At-Large Member, Physician
Steven Ross — Councilman, Las Vegas Alternate
Lawrence Weekly — Commissioner, Clark County Alternate

Staff: Scott Weiss; Angus MacEachern; John Middaugh; Glenn Savage; Jennifer Sizemore; Bonnie Sorenson; Mark Bergtholdt; Dennis Campbell; Ray Chua; Joy Clark; Alice Costello; Margarita DeSantos; Arta Faraday; Steve Goode; Forrest Hasselbauer; Chris Johnson; Angela Jones; Eric Lahr; Veronica Morata-Nichols; Patty O’Rourke-Langston; Mars Patricio; Walter Ross; Vickie Swanson; Whitnie Taylor; Leo Vega; Diana Lindquist and Shelli Clark, recording secretary

Attendance:

Name	Representing
Petya Balova	Balova Engineering
Doug Bell	Converse / Republic
Judie Brailsford	Self
Walter Crutchfield	Self
Chris Detwiler	Republic
L. Earl Hawley	NCC
Carisa Lopez-Ramirez	Catholic Charities of Southern Nevada
Ann Markle	Self
Carl Markle	Self
Joseph Mercado	NVCCU
John T. Moran III	Tropicana Las Vegas
Cory Nelson	Blind Center of Nevada
Bill Oliver	Tropicana Las Vegas
Todd Weiss	Self
Norine Clark	SEIU / SNHD

Recognitions:

Mutual of America Community Partnership Award 2010 Merit Finalist – Migration and Refugee Services

Dr. Sands reported the district was recognized by Mutual of America at the Community Partnership Awards earlier in the month for the partnership between the district and Catholic Charities, as well as numerous other agencies, for migration and refugee services.

Bonnie Sorenson, director of clinics & nursing services noted “refugee” status differs vastly from that of “immigration” status. Refugees come to the United States due to political or personal persecution and many have lost their families, their friends, their homes and ultimately their country. Coming to a completely new community is exceptionally difficult, particularly in making a fresh start in life. Catholic Charities became the center for accepting new refugees into our community and collaborated with many partners to help ease the transition for these individuals. Catholic Charities received the Community Partnership Award from Mutual of America and the district was recognized as one of the strongest partner agencies “for being an outstanding example of leadership in facilitation of partnerships between public, private and social sector organizations to better build communities for the future.” Carisa Lopez-Ramirez, of Catholic Charities of Southern Nevada, as well as Marie Ricci, community health nurse II, were honored individually for their efforts and received Silver Coins from Mutual of America. Each year ten honorees are selected out of thousands of applicants, and the district is honored to be one of the honorees recognized nationally. When a community pulls together and share even limited resources great things can be accomplished.

Ms. Lopez-Ramirez thanked the health district for its partnership in working with refugees. Refugee resettlement requires a collaborative effort in the community. Our program is the first refugee resettlement program to be recognized in the country. The main reason for selection is due the personal attention provided to new refugees in navigating the complicated medical system in southern Nevada, particularly for those who do not speak English.

Mrs. Sorenson noted that Gwen Osburn manages this program for the district and she is quite ill and may not be returning to the district. She has been instrumental in building relationships with physicians and obtained exceptional pricing for laboratory services. She built the program from the ground up and devoted much time and effort to ensuring its success. Mrs. Sorenson thanked her for her devotion to this program.

Vice Chair Jones thanked the staff, on behalf of the Board, for their support and work in this important community partnership, noting it is a great example of what can happen when collaborative efforts occur in providing service to the community.

I. Meeting of the Board of Health as governing body to receive information from its attorneys regarding potential and existing litigation involving matters over which the Board has supervision, control, jurisdiction or advisory power and to deliberate toward a decision on the matters – CLOSED SESSION pursuant to NRS 241.015(2)(b)(2)

Vice Chair Jones called for a motion for the Board to enter into Closed Session.

A motion was made by Member Christensen for the Board to enter into Closed Session pursuant to NRS 241.015(2)(b)(2); seconded by Member Vigilante and carried unanimously.

CLOSED SESSION

The meeting recessed for the Southern Nevada District Board of Health to meet in Closed Session at 8:37am. Vice Chair Jones reconvened the open session at 9:03 a.m.

(Member Scow arrived during Closed Session and was seated at 8:42am)

II. Report / Discussion / Action

Petition #29-11: PDF 239KB Approve Suspension of the Health District’s Budgeted Ending Fund (General Fund) Balance Policy for Fiscal Year 2012; or take other action as deemed necessary

Scott Weiss, director of administration presented on this item. Mr. Weiss noted the Board, on April 22, 2010, through support of staff, approved a recommended ending fund balance between 16.6 and 25 percent of the district’s annual operating expenditures, equating to between two and three months of operating expenses. This is in accordance with GFOA recommendations as well as a result of issues related to public health emergencies, cash flow, grants and other information presented to the Board at that time. Due to the possible approval of Petition #28-11 the policy must be suspended for fiscal year 2012; any changes will be brought back to the Board for consideration at such time necessary.

Vice Chair Jones confirmed the suspension of policy would only apply to the budget for FY12.

A motion was made by Member Chandler to approve the suspension of the health district’s policy pertaining to the budgeted Ending Fund Balance (General Fund) for Fiscal Year 2012; seconded by Member Christensen and carried unanimously.

Petition #28-11: PDF 5MB Adopt the Southern Nevada Health District’s Amended Revised Tentative Fiscal Year 2012 Budget Recommendation; or take other action as deemed necessary

Scott Weiss, director of administration presented on this item. At its April 28, 2011 meeting the Board approved the revised tentative budget for FY12 which provided for the full allocation of property tax at the full 3.5 cents per $100 of assessed value, in accordance with statute. Following submission of the budget to Clark County, the Board of County Commissioners took action on May 16, 2011 to reduce our budgeted property tax allocation from $19,870,482 to $5,692,495 for FY12. As a result of this unplanned reduction in funding and to better stabilize funding and ensure appropriate cash flow to meet the approved FY12 budget it is necessary to amended the previously approved revised tentative FY12 budget by allocating $13,267,525 from the general fund to the capital fund, leaving an estimated ending fund balance of 4.5% of the audited FY10 expenses.

A motion was made by Member Christensen to adopt the Southern Nevada Health District’s Amended Revised Tentative Fiscal Year 2012 Budget Recommendations as presented; seconded by Member Wood and carried unanimously.

III. 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.

Approve Minutes / Board of Health Meeting: 4/28/11 Held for separate vote

Approve Payroll / Overtime for Periods: 4/02/11 – 4/15/11 & 4/16/11 – 4/29/11

Approve Voluntary Furlough Program Reports for Periods: 4/02/11 – 4/15/11 & 4/16/11 – 4/29/11

Approve Accounts Payable Registers: #1285: 4/01/11 – 4/15/11; #1287: 4/15/11 – 4/28/11; #1290: 4/29/11 – 5/12/11

Petition #17-11: PDF 397KB Approval of the Continuation of the Voluntary Unpaid Furlough Program for Employees of the Southern Nevada Health District, Effective through June 30, 2012

Petition #22-11: PDF 343KB Approval of Recommendations for Appointment of Members to the Family Planning Advisory Council

Vice Chair Jones asked if there were any discussion on the items brought forward on the Consent Agenda. Member Wood asked to consider approval of the minutes separately as she would like to abstain from voting on that item, citing the reason of not being in attendance at that meeting.

A motion was made by Member Christensen to approve items #2-6 on the Consent Agenda as presented; seconded by Member Onyema and carried unanimously.

Approve Minutes / Board of Health Meeting: PDF 13MB 4/28/11

Member Chandler stated he would also abstain from voting on this item as he was not present at the last meeting. Member Menzel commented she also missed the April meeting; however previous counsel said Board members could not abstain from voting on an item unless there is a conflict of interest. Annette Bradley, legal counsel, noted there are reasons and circumstances whereby a Board member can abstain from voting on a particular item; the driver for voting on an item is whether or not the member has the ability and sufficient information to vote on the item. The overarching duty of a Board member is to govern the health district and integral to that duty is voting. Board member must vote honestly and if a member feels he does not have enough information to vote on a particular item, he may abstain from that vote.

A motion was made by Member Scow to approve the item #1 on the Consent Agenda as presented; seconded by Member Christensen and carried with Members Chandler, Menzel and Wood abstaining.

IV. Public Hearing / Action: Members of the public are allowed to speak on Public Hearing / Action items after the Board’s discussion and prior to their vote. Each speaker will be given five (5) minutes to address the Board on the pending topic. No person may yield his or her time to another person. In those situations where large groups of people desire to address the Board on the same matter, the Chair may request that those groups select only one or two speakers from the group to address the Board on behalf of the group. Once the Public Hearing is closed, no additional public comment will be accepted.

Consider/Approve a Variance Request PDF 6MB to Operate a Public Bathing Place not in Compliance with Nevada Administrative Code (NAC) 444.276 and 444.26.4 Located at Tropicana Las Vegas, Inc., 3801 Las Vegas Blvd S, Las Vegas, NV 89109 (APN: 16-28-101-001) for Health Permits: 30271-H2-18 and 30271-3H2-19. Petitioner: Joanne Beckett, General Counsel, Tropicana Las Vegas, Inc.; or take other action as deemed necessary

Vice Chair Jones declared the public hearing open.

Member Vigilante noted for the record that he is affiliated with the Tropicana with the food and beverage area.

Angela Jones, pool plan review supervisor and Whitnie Taylor, environmental health specialist II spoke on this matter. Ms. Jones noted that Ms. Beckett was unable to attend the meeting; John T. Moran and Bill Oliver were present to represent the Tropicana.

The petitioner requests a variance to eliminate regulatory signage at the Tropicana Lagoon Pool VIP and Spa, which states, “Children Under 14 Years Old Should Not Use Facility without an Adult in Attendance” and “Children 12 years of age or younger must be supervised by an adult and that the maximum recommended time for such children to use the spa is 10 minutes.” The request is supported by the fact that Tropicana intends to implement a policy that no individuals under 21 years of age will be allowed admittance to any of the referenced bodies of water. Nikki Beach Club is an adult European-style pool and spa and entrance to the pool and spa is gained through controlled entry into the Nikki Beach Night Club/Bar or a controlled admission gate from the pool.

Nikki Beach will not be accessible or useable by individuals under the age of 21. Employees/attendants are located at each of the three entrances, which will restrict access to the area to members of the public who are older than 21 years of age. The regulatory signage pertaining to children will be in direct conflict with the operational procedures of the Tropicana. Eliminating the required regulatory signage will not pose a danger to public health and safety because access to Nikki Beach will be monitored by attendants to allow entry to the nightclub/bar/pool/spa. In addition, attendants will continuously walk through the pool and spa areas to assist guests. All other regulatory signage will be posted.

Section 439.420 of the Nevada Administrative Code (NAC) states that a variance can be granted from a regulation only if it is found, from evidence presented at a hearing that:

There are circumstances or conditions which:

Are unique to the petitioner;

Do not generally affect other persons subject to the regulations;

Make compliance with the regulation unduly burdensome; and

Cause a hardship to and abridge a substantial property right of the petitioner; and

Granting the variance:

Is necessary to render substantial justice to the petitioner and enable him to preserve and enjoy his property right; and

Will not be detrimental or pose a danger to public health and safety

Whenever a petition for a variance alleges that he suffers or will suffer economic hardship by complying with the regulation, he must submit evidence demonstrating the costs of this compliance with the regulation. The Board will consider the evidence and determine whether those costs are unreasonable.

Staff is of the opinion that there exist circumstances which satisfy the requirements for a variance and that the granting of this variance will not be detrimental or pose an unreasonable danger to public health and safety if the following conditions as recommended are included:

The petitioner agrees to provide attendants, greeters or security guards during all open hours of the public bathing spa areas at all unlocked entrances, and to monitor access to these “adult only” areas;

The petitioner agrees not to open the public bathing spa areas to persons under 21 years of age (minors), unless signage in compliance with NAC 444.276 and NAC 444.526.4 is provided;

The petitioner agrees to post all other regulatory signage as required;

Failure of the petitioner to prevent minors from gaining access to the public bathing areas, as determined by the health authority, will result in voidance of this variance; and

This variance is automatically terminated without further notice upon the closing of any sale transaction involving the subject property, or upon petitioner leasing or assigning operation of these public bathing spas to any other person or entity.

Mr. Moran noted that pool plan review staff had been a pleasure to work with on the project and working through various issues. He further reported that Tropicana staff had provided additional information to staff to address concerns, including providing policies and procedures demonstrating that those under the age of 21 would not be admitted in to the Nikki Beach area.

The variance request also documents a plan with designated stations for two lifeguards, though the pool area is under the 2,000 square foot limitation. There will be a roving patrol around the pool edge to ensure public safety as well. Finally staff provided copies of the hours of operations for the two lifeguards to ensure there is always two lifeguards on duty to rotate coverage during breaks and lunch periods.

Vice Chair Jones asked if the parties understood and were in agreement with the conditions as specified; the parties responded affirmatively.

Member Chandler asked the harm of posting the regulatory signage and avoiding the variance process. Mr. Moran said the area is a small space and limited in posting required signage. The pool is only 900 square feet. As no minors are allowed in the area, it was felt the code was not applicable. Security staff has been instructed in the policies and procedures to not allow admittance to anyone under the age of 21.

Ms. Jones noted this is not a unique situation as other pools that are adult venues have come to the Board for variances related to signage including the Wynn/Encore, Cosmopolitan and CityCenter.

Vice Chair Jones asked if anyone from the public wished to offer testimony on this item. Seeing none, he closed the public hearing and called for a motion.

A motion was made by Member Wood to approve the Variance Request with the conditions outlined in the Memorandum and noted the request is in compliance with the specific conditions outlined by NAC 439.420; seconded by Member Christensen and carried unanimously.

Memorandum #14-11: PDF 10MB Consider/Approve Application for Gowan BuyBack Center – Republic Services of Southern Nevada (RSSN) to Operate a Solid Waste Management Facility – Recycling Center, Located at 333 West Gowan Road, North Las Vegas, NV 89032 (APN: 139-10-301-003); or take other action as deemed necessary

Vice Chair Jones declared the public hearing open.

Walter Ross, environmental health supervisor/engineer, and Chris Johnson, environmental health engineer I, spoke relative to this matter. Mr. Ross said that Gowan BuyBack Center has met all requirements to operate a recycling center as specified in Section 4 of the Regulations Governing Recycling Centers.

This facility must receive, store and process only source-separated recyclables for which there is an available market, meaning the facility will accept only source-separated aluminum cans, comingled glass, tin cans, mixed office paper, PET plastics and HDPE natural/color plastics. The facility will be open from approximately 8:00am – 5:00pm seven days a week. Chris Detwiler and Doug Bell representing Gowan BuyBack Center were present to answer questions of the Board.

Staff recommends approval based on the following conditions and a final inspection:

This facility, including all operations, must be in conformance with the information submitted in the Application for a Permit to Operate a Recycling Center submitted on June 24, 2010, as amended.

This facility, including all operations, must be at all times in compliance with the latest revision of the SWMA Regulations Governing Recycling Centers and all other applicable federal, state and local laws, statutes and regulations.

This facility must maintain approvals for applicable land use(s) and obtain and maintain applicable business license(s) and permits.

Member Chandler noted the facility is called a “buy-back center” and asked if the public will be paid for the recyclable materials brought to the site. He asked for representative rates of for aluminum, copper and glass. Mr. Bell said the facility will not accept copper. The only material accepted and purchased will be aluminum at the rate of $0.25 per pound.

Vice Chair Jones asked if the parties understood and were in agreement with the conditions as specified; the parties responded affirmatively.

Vice Chair Jones asked if anyone from the public wished to testify on this item. Seeing none, he closed the public hearing.

A motion was made by Member Scow to approve the application with the conditions outlined in the Memorandum; seconded by Member Christensen and carried unanimously.

Mr. Ross noted that all applications for approval related to Solid Waste Management Facilities include “Attachment A” in the accompanying memoranda, generally the third page, which denotes all materials to be accepted by the facility.

Memorandum #15-11: PDF 6MB Consider/Approve Application for a Temporary Permit for Blind Center of Nevada, Inc. to Operate a Solid Waste Management Facility – Recycling Center, Located at 1001 North Bruce Street, Las Vegas, NV 89101 (APN: 139-26-201-011); or take other action deemed appropriate

Vice Chair Jones declared the public hearing open.

Walter Ross, environmental health supervisor/engineer, and Arta Faraday, senior environmental health specialist, spoke relative to this matter. Mr. Ross said that Blind Center of Nevada, Inc. has met all requirements for a temporary permit to operate a recycling center as specified in Section IV of the Regulations Governing Temporary Permits to Operate Solid Waste Disposal Sites. The facility must also comply with Section V requirements including all design and operating standards for a recycling center.

This facility must receive, store and process only source-separated recyclables for which there is an available market, meaning the facility will accept only source-separated ferrous and non-ferrous scrap metals; HDPE plastics; and some e-waste including camera, computers, monitors, communication devices, copiers, printers, mass storage devices and audio/visual equipment. E-waste acceptance and recycling is an important part of the growing solid waste management system regulated by environmental health. The facility will be open to the public from approximately 8:00am – 5:00pm five days a week. Cory Nelson and Petya Balova representing Blind Center of Nevada, Inc. were present to answer questions of the Board.

Staff recommends approval based on the following conditions and a site inspection:

This facility, including all operations, must be in conformance with the information submitted on March 18, 2011, as amended.

This facility, including all operations, must be at all times in compliance with the latest revision of the Regulations Governing Temporary Permits to Operate Solid Waste Disposal Sites and the design and operating standards specified in the SWMA Regulations Governing Recycling Centers and all other applicable federal, state and local laws, statutes and regulations.

This facility must receive and maintain approvals for applicable land use(s) and obtain and maintain applicable business license(s) and permits.

The applicant must submit documentation of fire control approval.

The applicant must submit proof of financial assurance for closure of the facility.

The applicant must pay a fee for the Waste Management Permit after the temporary permit to operate is issued.

The temporary permit will expire six (6) months after issuance. The applicant will need to submit an application for a permanent permit, which is approved by the Board of Health.

Member Chandler noted all items are considered donations and no payment is made for items received. Mr. Nelson said customers are charged $15 for receipt of CRTs, which are large computer monitors due to the mercury content; the collected monitors are placed on pallets and shipped to California for processing. Member Chandler stated the facility offers great services to the community.

Vice Chair Jones asked if the parties understood and were in agreement with the conditions as specified, including acknowledgement that the temporary permit is valid only for six (6) months; the parties responded affirmatively. Ms. Balova said the facility is currently undergoing some remodeling; however an application for a full permit will be submitted soon.

Vice Chair Jones asked if anyone from the public wished to testify on this item. Seeing none, he closed the public hearing.

A motion was made by Member Wood to approve the application with the conditions outlined in the Memorandum; seconded by Member Christensen and carried unanimously.

V. Report/Discussion/Action

Board Education: PDF 1MB Board Governance, Part II

Dr. Sands reported this item is a continuance of the topic initiated in January concerning Board Governance. As the Board is currently in the process of adopting its initial Board Governance Policies (BGP), he asked counsel to provide additional information on the governance process, policy development and Board practices. The cornerstone of Board Governance Policies is the Board Governance Process, which is the foundation from which all policies flow. It is anticipated that this draft policy will come to the Board for consideration at the June meeting. Today the Board will consider adoption of two new BGPs pertaining to Board Officers /Member and Committees.

Annette Bradley, legal counsel, shared a PowerPoint presentation (attachment #1). PDF 3MB At the January meeting Ms. Bradley asked three questions: how can a group of peers 1) exercise responsible oversight over activities they will never completely see; 2) exercise authority over/through disciplines they may have little familiarity with; and 3) fulfill their collective accountability obligation while simultaneously empowering management to do the work with which it is tasked. The answer is simple: policy governance. Through governance the Board exercises the art of steering the organization. Policy governance emphasizes the flow of authority, ethics, values, organizational purpose, mission and the framework for strategy.

Policy development is key under the policy governance model. Board should develop four different governing policies which are necessary for accountability and role clarity which are:

Ends: a clear description of goals, reflecting expectations and benchmarks for success;

Board/CHO (Chief Health Officer) Linkage: the delegation of authority and accountability to management, thereby distinguishing between the jobs of board governance and organizational management (e.g. only officially passed motions of the board are binding on the CHO; individual Board member requests/comments are not considered binding);

CHO Limitations: definition of effectiveness and responsibility, which limits behavior by keeping management from using unacceptable means to accomplish the mission. Of necessity this category of policies is framed in negative terms because it limits behavior – what is not forbidden in policy amounts to automatic approval by any “reasonable interpretation” of the policy.

Governance Process: the purpose for which an organization was created and is concerned with activities of the highest level including planning, goal setting, policy development and monitoring progress toward strategic objectives.

The Board Governance Process is in essence the Board’s job description and defines how the Board operates as a whole, the process it employs to accomplish that work, and how that work will be monitored. Board Governance is about leadership, relationships and shared goals between the Board itself, the CHO and staff. The components of a Board Governance Process include the concepts of commitment, governance style, guiding principles and clarification of its roles and responsibilities. This particular policy is the foundation for the Ends, CHO Limitations, and Board/CHO Linkage policies, as well as setting the tone for other future Board oversight policies.

The Board should hold itself responsible to Southern Nevada residents and visitors. As such the Board commits to ensuring achievement of the three-core public health functions: assessment, policy development and assurance.

A Board Governance Policy reflects the Board’s governance style and sets an organizational tone. This style can optimize focus, teamwork and self-discipline. It can also be a driver for inclusiveness in deliberations, being proactive and strategic leadership. Further it can establish clear boundaries for the roles of the Board and the organization itself.

As a collective body Boards often struggle with the question of how much it wants to be involved, and if it is doing too much or too little. The governance spectrum reflects the conundrum of style. Ms. Bradley offered the example of how work is conducted in a kitchen with a chef and his staff. A working board stirs the soup; a managing board tells the chef how to make the soup; a governing board tells the chef the kind of soup it wants and leaves the kitchen. The draft Board Governance Policy presented today reflects a collaborative governing style that emphasizes outward vision, encourages strategic leadership rather than administrative detail and maintains a distinction between Board Governance and the CHO.

The linkage between the CHO and the Board is defined by roles and relationships. When the roles and lines of communication among the Board, its committees and the CHO are clearly differentiated potential for overlap, gaps and ambiguities are avoided. When the linkage is clear, the CHO will know when work is passed to them – everyone understands their role and what to do.

The Board Governance Process defines the roles of the Board and management. It differentiates between the Board’s purpose and management’s performance. It is the difference between strategic leadership and tactical leadership; between values, mission, vision, strategic goals and priorities and program leadership structures, plans and goals; between ends or strategic outcomes or means; between the impact the organization desires and how the organization impacts people, programs and activities. In sum Board Governance measures, monitors and ensures the CHO’s accountability, while management supervises the staff.

The Board as a whole determines its guiding principles which ultimately flow from the Board to staff and will include:

Determining what the organization wants to achieve and communicate;

Providing strategic leadership that is focused on the future;

Respecting each other’s roles, interests and accountabilities;

Adhering to the Board’s mandate of long-term oversight and policy-making while ensuring the CHO’s responsibility for daily oversight for operational matters;

Operating as a corporate body, speaking with one voice;

Regularly monitoring both organizational and CHO performance;

The Board has only one “employee” who is the CHO and his/her work is measures by results; and

Individual Board members and the CHO are colleagues; however the Board as a whole is superior

The Chief Health Officer serves as the link between the Board of Health and staff. Staff’s focus is on the present while the Board’s focus is on the future. The Board has the sole authority to govern; the CHO will manage and staff will implement; finally staff is accountable to the CHO, who in turn is accountable to the Board, and the Board is accountable to the community.

Consequences of effective Board governance include:

A well-functioning Board

Real accountability

Clarity of purpose

Transparency and openness

Sound Board-staff relationships

Results that matter

Ms. Bradley closed by stating that success is a function of choice not circumstance. As the Board reviews the draft Board Governance Process policy it should be done with the context of policy governance style, the mission and core values, and the distinction between how and what is done versus what is to be accomplished within the organization. The Board Governance Process is the beginning of numerous substantive policies which reflect the Board’s composition and how it intends to govern the organization.

Vice Chair Jones thanked Ms. Bradley for providing an overview on how the Board can move forward while ensuring a successful future. Ms. Bradley noted additional supporting document was also provided. Dr. Sands said the information will be available on the website as separate documents from the agenda link, including a link to the Carver Governance Model website. He noted that the Carver model is a well-recognized standard and the Clark County School District employs this model. He asked the Board to please review the draft policy and provide feedback so the appropriate revisions can be made before the final draft is presented to the Board for adoption.

Consider/Adopt Proposed Board Governance Policy (BGP)-004: PDF 925KB Committees

(Member Vigilante left the meeting at 9:42am)
Annette Bradley, legal counsel, stated this policy explains the composition and purpose of Board committees. There are several committees currently defined but many do not have charters, guidelines or a firm description of what the committee is to accomplish. Under the Carver model committees are not used as “governing tools” but rather as assistance as needed with a defined beginning and end. There should not be too much reliance on committees which can lead to the Board’s engagement with health district guidance and strategic leadership.

Member Menzel asked that under 2.A the phrase “less than” be changed to “fewer.”

Member Scow noted she has been through the Carver training. She expressed concern with the allowance of standing committees as referenced in 1.iv; the Carvel model recommends that all committees should have a defined purpose and ending date. Without a defined purpose or sunset a committee could become a Board within itself when the full Board should take responsibility for that particular area of focus.

(Member Vigilante returned to the meeting and was seated at 9:46am)
Ms. Bradley remarked that if the Board is in agreement with any changes recommended at the meeting the policies could be adopted today. Otherwise the edits can be made and the revised policies brought back for adoption at the June meeting.

Member Scow said this type of governance process is very successful in the Clark County School District, though the Board did receive criticism for not having more control over operations. Member Scow said in her experience it was completely opposite by setting the tone for what policy should be and how budgets should be formulated. The Board sets the desired outcomes. At the end of the year, the Board can conduct a data-driven evaluation of the chief official due to the power of the various governance policies.

Member Scow asked if the Board currently has standing committees in place. It was noted the Audit and Replacement Facility Committees are standing. Member Scow recommended phasing out the standing committees. Member Christensen suggested reevaluating current committees and determine how the work can be carried out differently. He noted the Audit Committee needs oversight and membership should be rotated to allow all Board members to share that responsibility.

Vice Chair expressed his agreement with this remark. The current function of the Audit Committee is to receive information and bring recommendations to the full Board for consideration. There is no independent action taken by the Audit Committee. Dr. Sands said historically committees have reported to the full Board before action is taken, and are not independent of the Board. He confirmed that the draft policy provides for a review and evaluation of the purpose of each Board committee annually to determine what changes are necessary or if the committee is still needed.

Member Christensen said the Board needs to move towards being both policy and data-driven. The CHO should be evaluated by CDC guidelines and healthy measures of the community, as well as how we can move towards the goals set by CDC and larger governing bodies.

A motion was made by Member Scow to approve BGP-004 as presented with the requested grammar change; seconded by Member Christensen and carried unanimously.

Consider/Adopt Proposed Board Governance Policy (BGP)-005: PDF 922KB Board Officers/Members

The health district was created by statute, including the establishment of the district board of health and its composition. Though the statute defines the election of a chair it is silent on other officers. It is being recommended that the Board officers include at least one (1) elected member. Vice Chair Jones noted this has been the case historically. Dr. Sands said this type of defined leadership better reflects the composition of the Board as a whole.

Member Chandler questioned potential for problems with divergence from the statute and if the Board has authority to do so. Annette Bradley, legal counsel, said the Board has the ability to adopt policies and regulations to govern the health district and there is nothing in statute to limit the officers and who can serve as an officer. The Board is composed of both elected and at-large members; the non-elected at-large members are selected by the elected members of the Board per statute as referenced in the policy under item 5.B. The statute is silent on how leaders are identified so there is flexibility for the Board to determine its leadership.

Member Menzel suggested item I.B be changed to read “for whom” versus “for who.”

Member Christensen said at least one elected member has always served in a Board leadership position.

Member Scow said the community would want an elected member to serve as the Chair, as this person is representative of the taxpayers. Member Chandler said it is practice for the Vice Chair to be elected the Chair and suggested if the Chair is to be an elected member the Vice Chair should also be an elected member.

Dr. Sands said most boards do have elected members serving as chair; however the Board of Health’s composition changes from year to year which can affect Board leadership as well. We have little control over the Board’s actual composition and who is assigned from each jurisdiction.

Member Christensen said under Dr. Ravenholt and Dr. Kwalick the chair was someone with a strong public health or medical background as the goal of the Board is public health policy and ensuring a healthy community exists. Though we must use taxpayer dollars to reach this end the Board works as a whole to meet these goals, as both elected and non-elected members. The mission of the Board is to protect the public’s health and safety and promote a healthy community and encourage healthy habits. He continued that having one elected member serve in a leadership role meets the spirit and intention of the statute. He commented that the hepatitis C outbreak was a dark time for the community and it was through great leadership that we weathered that storm, but together we deal with the outcome.

Member Scow said she was convinced that the Chair did not have to be an elected member, so long as one elected member served in a leadership position.

A motion was made by Member Chandler to adopt BGP-005 as presented with the requested grammar change; seconded by Member Onyema and carried unanimously.

Petition #23-11: PDF 6MB Approval of Revocation of Southern Nevada District Board of Health Permits to Operate a Solid Waste Management Facility, Permit MRF01-XXX-01 and Permit RC045-XXX-01, in the Case of Nevada Construction Clean-Up (NvCCU), 2745 North Nellis Blvd., Las Vegas, NV 89110 (APNs: 140-17-703-002 and 140-17-703-005); or take other action as deemed necessary

This item will be moved to the June 23, 2011 meeting as the facility is continuing its closure process.

Petition #25-11: PDF 4MB Approval of Initiation in New Family Planning Services (Planning Options without Exam Required – P.O.W.E.R.) and Associated Fee Schedule Charges; or take other action as deemed necessary

Bonnie Sorenson, director of clinics & nursing services, and Alice Costello, public health nurse manager presented this item.

Ms. Sorenson said the purpose of the petition is allow the nursing staff to provide birth control to patients meeting the defined criteria without a pelvic exam. This would allow our practices to be in accordance with the American College of Obstetrics and Gynecology (ACOG) guidelines, as also endorsed by the World Health Organization and the Centers for Disease Control & Prevention (CDC). A pelvic exam is not recommended prior to age 21 unless there are other mitigating circumstances such as discharge or medical history. As the issuance of birth control will now be a limited exam, a reduction in fees is justified.

Vice Chair Jones sought to confirm this would be a best practice. He asked if there is any type of medical liability if something is missed due to the lack of a pelvic exam. Ms. Bradley said this is being done under protocol and we can only rely on the information provided by the patient. There is no requirement for significant detail for the medical history to uncover a potential disease – the focus of this exam is very narrow and pertains only to issuance of birth control based on information provided by the patient.

Member Christensen said the risk for oral birth control comes later on and pertains to lifestyle choices, namely related to smoking a risk of thromboembolisms, as well as any unusual genetic tendencies. Most exams are conducted by APNs and under policy the medical director has signed off on which follow evidence-based best practices. We need to reduce the fee to better reflect the type of service provided. Ms. Sorenson said we are also removing barriers for individuals as the pelvic exam can be seen as a deterrent for those women seeking birth control.

Dr. Sands said the incidence of abnormal pap spears in a person under the age of 21 is very rare. If there are other problems they will manifest themselves in other ways besides a pap smear.

Member Onyema said his initial concern was the potential of endangering the public’s health by not screening for STDs. This exam provides an opportunity for education regarding sexual health. After further reflection he feels this practice is helping the Board meet its obligation to protect the community. Vice Chair Jones confirmed that income level is by self-disclosure.

Scott Weiss, director of administration, asked that any motion to approve include the effective date of this change as July 1, 2011.

A motion was made by Member Christensen to approve the Planning Options without Exam Required program with the accompanying family planning fee schedule change effective July 1, 2011; seconded by Member Wood and carried unanimously.

Petition #24-11: PDF 629KB Approval of Southern Nevada Health District Chief Health Officer, Division Directors and Human Resources Administrator Compensation Plan for FY July 2011 through June 30, 2012; or take other action as deemed necessary

Angus MacEachern, human resources administrator, presented this item. Effective with the first full pay period in July a PERS increase will be in effect for all PERS employees in Nevada, which equates to 2.25%. In an instance where an employer is not providing a general salary increase the law states the increase must be split evenly between the employee and the employer; the employee portion must come from a salary reduction unless there is an off-setting salary increase. Staff is asking the Board to approve a reduction of 1.125% in salary for the executive service employees related to the PERS increase effective July 9, 2011.

In response to questions and concerns regarding executive longevity it is proposed that all payments be frozen at the current levels until such time the matter can be addressed through the classification & compensation study. Savings are listed in the materials provided to the Board, which is approximately $15,300 annually.

Vice Chair Jones stressed the issue of compensation and longevity for all staff will be fully addressed in the classification & compensation study.

A motion was made by Member Anthony to approve the SNHD Chief Health Officer, Division Directors and HR Administrator Compensation Plan for FY12 as presented; seconded by Member Vigilante and carried unanimously.

Receive Report from Staff on Adjusted Work Schedules (4/10s); and direct staff accordingly.

Dr. Sands asked for Angus MacEachern, human resources administrator to discuss how adjusted work schedules (AWS) are used throughout the district, particularly 4/10s. Bonnie Sorenson, director of clinics & nursing services and Scott Weiss, director of administration were also available to discuss services at three of the public health centers where the schedule changes are occurring. The main public health center will continue to provide full services to the public five days per week, though some programs do function on AWS based upon the work provided and the public served by that particular program.

Mr. MacEachern started by stating that work schedules need to be set to best serve the clients seeking a particular service. In government service the standard operating hours are 8am–5pm, Monday–Friday, being closed on legal holidays as determined by state law. In providing public health services, some services must be provided on an extended hours basis – for example some services are provided on Saturday mornings, early weekday mornings or late weekday evenings. The TB Clinic is open from 7am – 5:30pm daily to allow clients undergoing direct observed therapy (DOT) to take their medication either before or after work, which is more convenient for our clients.

Another example of extended service hours is within the solid waste section. Staff working with replacement of gasoline tanks, which is done in the early morning hours in the summer months and inspectors can be on site at 5:30am and work an adjusted schedule to meet this time variance. Staff may work a Monday-Thursday or Tuesday-Friday schedule to meet the needs of the contractors; yet staff remains available five days per week for service to the industry.

Staffing is based upon the needs of the public, and available staffing levels. Some staff in nursing may work Monday-Thursday, Tuesday-Friday, or a varied schedule with Wednesdays off, while maintaining a 4/10 schedule. Some workgroups across the district also work a 9/80 schedule, where the 80 hour schedule is done over 9 days versus the standard 10 days; staff will work 9 hours for 8 days, one day at 8 hours and be off the tenth day. Again this is done to benefit the needs of the public where services may be needed early in the morning or late in the afternoon. The primary reason for an AWS is customer service and business need.

There is a growing need for extended hours of nursing services, including immunizations, and health cards at the outlying public health centers (PHC), including East Las Vegas, Cambridge and Henderson. Extended hours allow parents to bring their children in for immunizations after their work day ends. By closing our clinics at 4:30pm parents are not able to obtain needed services when they may be available to come in. By extending service hours by one hour, we are better meeting the needs of the public. Most parents are not coming into the clinics on Friday afternoons for immunizations – this service is most often sought on Monday-Thursday afternoons.

The extended clinical hours going into effect on June 13th is on a trial basis and will be reviewed at both three-month and six-month intervals. Staff was consulted before implementing the operational change to ensure the change was voluntary.

Ms. Sorenson indicated Board members were provided with a copy of the nursing division schedule and the services provided (attachment #2). PDF 523KB There is not enough staff to stagger extended hours five days per week; however services are provided over 40 hours per week across the various programs. The 4/10 schedules being implemented at the East Las Vegas and Henderson PHCs is in response to customer services surveys administered as a requirement of Title X, and clients have asked for later clinical hours of operation. It is impossible to predict client flow for walk-in clinics; however where there are more controlled environments, such as appointments for service, it is easier to stagger staff for extended hours. Previously a pilot of extended hours was done at the main health center clinic, however it was very difficult to provide services when staff called in sick and the division was running short-staffed which resulted in long lines for service.

Vice Chair Jones inquired about the STD clinic which offers extended hours. Ms. Sorenson said many clients come to this clinic at 4:15pm seeking service. To better control overtime costs, some staff in the clinic have later working hours, which helps process any late arrivals to the clinic. This is also done in the immunization clinic at the main clinic. It is crucial to provide HIV clinical hours five days per week, though surveillance occurs seven days per week. As there is ample staff, employees are able to work a 4/10 schedule while ensuring services are provided throughout the community. Disease Investigators/Intervention Specialists work late hours as they are out in the community on a daily basis – having an AWS is working well for this program, as well as the community served. Late afternoon/early evening appointments for clients in the Nurse Family Partnership are also working well so the young mothers can remain in school.

Ms. Sorenson noted the extended hours is a work in progress and there may be changes going forward. Management ensured adherence to the contract when the schedules were being developed and involved the union in the process. There are some employees who found difficulty with the proposed changes, and accommodations where made, which may not necessarily be in the same work area but it is the right of management to determine where employees work. Ms. Sorenson stated staff signed forms agreeing to volunteer to move to the 4/10 schedule, and there were actually more volunteers than available positions for extended hours.

Member Christensen said these extended hours are better serving the needs of the population, however we need to look at having clinical hours on the weekends, including Saturday mornings. Many emergency rooms and urgent cares experience a spike in patient flow on Fridays and weekends, including late hours. Ms. Sorenson stated that in reviewing patient profiles we see many clients who work in industry which may have varying days off each week, such as Monday or Tuesday. Though this change is not a perfect solution, we are trying to offer services to as much of the community as possible with available staffing.

Dr. Sands noted public demand for weekend hours more often applies to acute care. Member Christensen said immunization services is more chronic care and to address the barriers to immunization we may need to offer services outside the norm of Monday-Friday and consider a Wednesday-Saturday work schedule for some employees. Ms. Sorenson reported that Back-to-School clinics are operational seven days per week for a two-week period, and this will continue going forward. We will continue to survey the clients about the extended hours and make changes as necessary.

Member Onyema said we need to continue to provide services to the community with the limited resources available. Further it is impossible to predict when clients will seek services and the community will adjust their schedules to when public health services are available. We need to continue to provide services during the summer to ensure children can receive necessary immunizations for school entry.

Member Menzel commented this discussion is more a management issue and in the spirit of what was discussed previously the Board should be looking at governing issues and not management’s decisions. Dr. Sands said at the previous meeting questions were raised about the decision to institute 4/10 schedules at certain centers which would be closed on Fridays, and staff committed to update the Board relative to the 4/10 schedules for the nursing division.

Vice Chair Jones said the report is purely informational with no action necessary from the Board. He agreed that it is management’s responsibility to manage the health district.

Ms. Sorenson asked about the success of the City of Las Vegas’ conversion to a 4/10 schedule; she noted that the Cities of Henderson, Boulder City and North Las Vegas also operate on a 4/10 schedule. Often times clients are surprised the health district is open on Fridays as so many jurisdictions are closed at that time. Member Anthony said there have been no problems at the City since changing to a 4/10 schedule.

VI. Public Comment:

Public Comment is a period devoted to comments by the general public, if any, and discussion of those comments, about matters relevant to the Board’s jurisdiction will be held. No action may be taken upon a matter raised under this item of this Agenda until the matter itself has been specifically included on an agenda as an item upon which action may be taken pursuant to NRS 241.020.

Vice Chair Jones asked if anyone wished to address the Board. He noted that speakers will be limited to five minutes.

Norine Clark, chief steward for SEIU. She stated she has worked hand-in-hand with management in addressing the need for extended hours and the shift to a 4/10 schedule for some clinics. She acknowledged management’s efforts in trying to work with staff and address concerns. She said many nursing employees were anxious to work a 4/10 schedule and have one day off per week; however there are many other employees experiencing hardships with the schedules, particularly single parents, those with children in daycare, and those employees taking classes at the university for career advancement. Ms. Clark said when employees are given a choice to work new hours or be reassigned it is difficult for some employees to make this decision, recognizing this is the right of management. Some employees have left the district because they were unable or unwilling to work a 4/10 schedule and did not want to be reassigned. She said that employees should have the right to refuse a change in work hours when there are extenuating circumstances. She noted that employees outside of nursing were affected by this change, including maintenance and security, who also were required to change their work schedules. Union members will continue to address concerns through the negotiations process. Ms. Clark said employees are here to serve the public but we need to ensure that schedules are based the needs of the community and other avenues should be explored such as weekend hours. She expressed concern for those clients that take the bus to the health district for services, particularly those with children, and it is important to be mindful of this aspect as well.

Vice Chair Jones asked if anyone else wished to address the Board. Seeing no one, he closed the Public Comment portion of the meeting.

VII. Board Reports:

The Southern Nevada District Board of Health members may identify emerging issues to be addressed by staff or by the Board at future meetings, and direct staff accordingly. Comments made by individual Board members during this portion of the agenda will not be acted upon by the Southern Nevada District Board of Health unless that subject is on the agenda and scheduled for action.

Vice Chair Jones asked Board members if there were any information to report. Hearing none, he closed this item.

VIII. Health Officer & Staff Reports

2011 Charles C. Shepard Science Awards
The Centers for Disease Control and Prevention (CDC) announced Dr. Sands, Brian Labus, Patricia Armour and Patricia Rowley and their co-authors from CDC and the Nevada State Health Division (NSHD) as nominees for the 2011 Charles C. Shepard Science Award in the area of Assessment and Epidemiology for a joint article which appeared last year in the Journal of Clinical Infectious Disease, entitled “Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007–2008.”

Community Transformation Funding Opportunity Announcement
The US Department of Health & Human Services announced last week the release of a Funding Opportunity Announcement (FOA) for the Community Transformation Grants (CTG) initiative, which is funded through the Affordable Care Act. This is in follow-up to the Communities Putting Prevention to Work (CPPW) grants, of which the district is in receipt of two sizeable grants for tobacco use prevention and obesity prevention. Staff has been in discussion with CDC over the last several months regarding eligibility criteria for grants to allow local health departments and districts serving a large population to compete for these grant opportunities directly. As the criteria haves been modified accordingly, the district plans to apply for this grant opportunity.

(Member Onyema left the meeting at 10:45am)

Deborah Williams, chronic disease prevention and health promotion manager, noted staff’s excitement in applying for the Community Transformation Grants funding. In year one there will be a total of $102 million available to fund up to 75 communities. The first year will start September 15, 2011 and the five year project cycle will end September 14, 2016. As it takes a substantial amount of work and time to transform communities, the grant period is significantly longer than the two-year cycle for the CPPW grant. Staff will write a budget for the first year for the grant application; if funded, we will not have to compete for subsequent funding for the balance of the grant cycle, we will only need to submit an appropriate budget. We are eligible for direct funding and if awarded the funding will not pass through the state – direct funding criteria is restricted to states, cities, counties, districts and tribal entities, as well as non-profits, who can document a service area of greater than 500,000 covered lives.

When applying for the CPPW grant, staff had to choose from a prescribed set of MAPPS (Media, Access, Point of Purchase, Price and Social Support) strategies; for this grant opportunity staff must select from prescribed evidence-based strategic directions, which have been researched and proven to work in multiple environments. Staff is reviewing the strategies and will select those making the most sense for our community. Requirements include addressing tobacco-free living, obesity prevention through active living and healthy eating, and increased use of clinical preventive services focused on control of high blood pressure and high cholesterol. The application will build on the success and partnerships of the current CPPW application, but will continue and expand upon the program, and is due July 15th.

Vice Chair Jones asked for clarification on the amount of the grant award. Ms. Williams reported the $102 million in the first year will fund up to 75 communities. Applicants may compete for capacity building or implementation. Based on the capacity building and resources staff compiled in conjunction with the CPPW grant, we meet the eligibility criteria for implementation, the funding range of which is between $500,000 to $10 million for the first year. Based upon the availability of funding, successful applicants will be able to apply for the same funding level or more in years two through five.

Dr. Sands noted the funding starts September 15, and there would be an overlap of funding with the two CPPW grants for a short time. The CPPW tobacco grant expires in March 2012; the CPW obesity grant expires in September 2012. Unlike other grants or cooperative agreements which typically expire after two to three years, this grant opportunity could be funded for as long as five years which would provide the community an ample opportunity to have activities in place and build an infrastructure that demonstrates an impact on the community. Like other federal grant opportunities, this would be a reimbursement grant.

Walter Crutchfield approached the podium and asked to address the Board. Vice Chair Jones noted the Public Comment portion of the meeting was closed. Ms. Bradley confirmed the Public Comment section was closed. Mr. Crutchfield stated his attorney was going to address the Board, but was unable to attend the meeting for personal reasons; his assistant advised to wait to speak until the proper time. Vice Chair Jones confirmed the proper time had passed. Mr. Crutchfield asked for a few minutes to speak. Vice Chair Jones asked the Board if they would entertain Mr. Crutchfield’s comments for three minutes and the Board concurred.

Mr. Crutchfield shared a letter with the Board (attachment #3) PDF 750KB addressing his concerns with the revocation of his environmental health permit to perform permanent make-up services due to use of in appropriate equipment. He has been unable to obtain a new permit, even though seven years have passed. He asked the Board to review his case and allow his permit to be reinstated.

Vice Chair Jones thanked Mr. Crutchfield for his comments and asked staff to update the Board relative to the status.

IX. Informational Items - Duly Noted

Chief Health Officer and Administration:

Monthly Activity Report, Mid-April 2011 – Mid-May 2011 PDF 754KB

Financial Data: Revenue and Expenditure Report for General Fund, Capital Reserve Fund, Bond Reserve Fund, Insurance Liability Reserve Fund, and Public Health Laboratory Fund for the Month of April 2011

Grant and Agreement Tracking Report, as of May 7, 2011

Public Information Monthly Report, April 2011 PDF 18MB

Letter of Appreciation from Family to Family Connection regarding Susan Eiselt, administrative secretary

Community Health:

Monthly Activity Report, April 2011 PDF 5MB

PEWSS Bulletin 4-06-11

PEWSS Bulletin 4-13-11

PEWSS Bulletin 4-20-11

PEWSS Bulletin 4-27-11

April 2011 Disease Statistics

Environmental Health:

Monthly Activity Report, April 2011 PDF 2MB

Clinics and Nursing:

Monthly Activity Report, April 2011 PDF 3MB

In-service calendar

Appreciation/Recognition Correspondence

IX. Adjournment

There being no further business to come before the Board, Vice Chair Jones adjourned the meeting at 10:55 a.m.

SUBMITTED FOR BOARD APPROVAL

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

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