ALC-Administrative Rules

To get started here in just about another thirty seconds so if you will ever see we're gonna kick it off. Okay. Folks we're going to call the meeting to order. You have a report from the executive subcommittee in your packet regarding its approval for an emergency rule. Do I have a motion to adopt the report. I have a motion and second all in favor say aye. All opposed. Motion carries in the report is adopted. Our next moved to item city. Administrator reports on administrative directives well someone from the department of corrections please come forward introduce yourself and you may present your rule. Hello hi if you would introduce yourself and you may be yes sure good morning Mister chair and committee members my name is Lindsay Wallace I'm the chief of staff for the secretary's office FOR the department of corrections and this morning I'm here to present to you the second quarter report on administrative directives and going through the memo beginning with the secretarial directive summary. SD twenty dash zero four dress code for uniformed personnel for non uniformed personnel. This directive was updated to define acceptable and unacceptable footwear for non uniformed employees SD twenty dash zero five concerning the employee assistance program this directive was created to inform employees and how to access support services available to them to the state's employee assistance program. Moving to the division of correction administrative directives AT thirteen dash ninety four concerning the employee assistance program this repealed and replaced it was repealed and it was replaced by the employee there are the secretarial directive twenty dash zero five concerning the employee assistance program. AT twenty dash zero three concerning emergency furloughs this directive was updated to clarify the definition of the immediate family as it applies to this policy language is added to adjust the time frame for furloughs by excluding travel time the update also provided instructions for barred officers who would like to request reinstatement to the approved escort list. AT twenty dash zero four concerning publications this directive was updated to clarify the procedure for reviewing incoming publications and the definition of materials that advocates for assisting criminal activity language was also added regarding photo books and product inserts AT twenty dash zero five concerning inmate withdrawal request this administrative directive was revised to clarify the inmates your terminated from a work release program are only allowed to spend ten percent of the total amount of funds made during their participation in the program the remaining balance will be given to the inmate upon release either through parole or discharge of the sentence information was also added to clarify that if an inmate wants money transferred to their family final approval must be granted by the director prior to release of any funds. AT twenty dash zero six concerning inmate property control this administrative directive was revised to clarify the inmates must submit a stolen property report for any missing or stolen property failure to submit a report will release the division a correction from any liability for missing or stolen property. AT twenty dash zero seven concerning physical assessments this administrative directive was created to combine too largely duplicative directives and those two policies that were repealed and replaced by that a deer listed below eighty thirteen dash thirty and eighty fourteen dash zero two. And the next thing is administrative memos issued by the division of correction. A. M. twenty dash zero one concerning service weapons the purpose of this administrative memo is to clarify that a retiree must have been issued a weapon for at least fifteen years during the duration of his or her service time in order to be eligible to receive their weapon upon retirement. I'm for the division of community correction there were no administrative directives or administrative memos issue during the second quarter of twenty twenty and that concludes this report. Senator hammer you're recognized thank you Mr chair I have a question about AT twenty dash zero five the inmate withdrawal request sure yes Sir when it says that the they've been terminated from work release is that terminated by the employer terminated by the department or either or. Let me pull up the policy and look at it. It just the policy just says that an inmate was terminated from a work release unit so I would assume that they are no longer working in the work release program but I can ask for clarification on that and provide it to you if you would please okay let me ask you if they are terminated for either reason by the department or by the employer and they have a balance in there. And it involves child support that supposed to be going. Just does that a bounce does that bounce get drawn down on a consistent basis so as to make sure that the child support flows through. Child support is addressed in the policy but I don't know the specific answer to that question can I find that out and respond to you okay great yeah I just wanna make sure that that the child support is the property item and that they don't get the money and walk out there without the child support being paid yes Sir I understand all right thank you ma'am no problem thank you Mr. And if you would direct your response to the committee and we'll get that out there about a full day members for I don't see any for the questions house so without objection this report is reviewed and filed thank you. And next we have a report from the parole board. Thank you Mr chair I'm also going to present a douche yourself again player I'm Lindsey Wallace I and the chief of staff for the secretary's office FOR the department of correction at concerning this report the parole board did not revise or issue any administrative directives during the quarter ending June thirtieth twenty twenty. Members I see no question so with no further questions about objection this report is reviewed and filed thank you thank you. Members from move to item D. number one the department of commerce. If you would please introduce yourselves and you may begin yes good morning Mr chairman members the committee my name's Eric Monson on the commissioner of the Arkansas securities department and on my left on your right is Mister David Smith our chief legal counsel valid introduce themselves place thank you. If you go ahead entities yourselves to. Good morning I'm I'm David Smith the chief counsel at this securities department thank you. Hi am can't hear them an attorney with the securities department okay thank you you may begin. Can be wise this matter in turn charge if counsel to give you summary. On this thank you. A again your morning committee up we we have a. Relatively shortly AS the several things that we are proposing and are amended rules or clean up language to clarify and. And it makes some some of these provisions or as little is that adding a Perrin around things but there are two of principal areas that were proposing and both of those involve model provisions that are countrywide or or act actually all proposed by or their their model language adopted by an organization this encompasses all of North America in in those two areas. One of them involves of merger and acquisition brokers and that something that mass of the national association of. Securities administrators adopted several years ago and we had provisions for that within our rules but we had we've had requests from attorneys local attorneys asking Hey you know or you all cannot adopt this national language it really helps out and so we that's what we're running and it in that area in fact just last week we had a third attorney callous and say. Okay could you all do something about this adopt the model rules so that's that's what we're doing in that area it's it's an area where some people. Might be a dream to be regulated within our ACT and there's really no need and with in this model provision of it it provides all the safeguards needed another area that Senate again Model language is that we want to adopt it concerns cyber security and that she is an area that yes not addressed in our acted rules that to in today's climate really needs to be addressed and that's the protection of of the clients so that a broker dealers investment advisors or providing proper protection for information on clients. The Representative love you're recognized for a question thank you I'm going to go back to the former that you were mentioning. I'm not adopt and you decide Massa rules right SO that doesn't have anything to do with the space administration it's the north American securities administrators association okay now I I guess I'm trying to figure out what is this is Stanton change did some of these attorneys want to see and what what impact does it have the best I guess if we don't have it now on I'm trying to figure out why should we adopted in debt and and don't tell me just because it's an incident you know a model I just need to know the substantial change. Right and the concerning the mergers and acquisition brokers. Of the this provides an exemption from registration so that certain people that are in the middle of a deal to put two businesses together where securities are involved this provides an exemption so they don't have to register with us to do that and it has enough provisions in there that. provides the protection so at the all the parties are protected within this it has specific detail center about the the size of the transactions that the size of the companies involved and and again so what will we not want them to disclose who they are in in other parts of it. I'm sorry. Laundry one changes in. Our well so It says so in order to. The if they had to register with us. Their exams involved and registration fee is they just don't fit a typical broker dealer situation by people that sell stocks and bonds and they have agents registered with them that those are the people that we regulate and and this really doesn't fit that so with in the rule or protections for in any there are things like these people can have a the criminal history in other things this bad boy provisions within it spree for a fairly it's a good size rule I think it goes for couple pages to have all those protections in it and again we had private attorneys contactus eight in we had someone which within our rule already within the definition section to provide for this it just didn't do it is thoroughly in as well is this will do it so You know this this is something that will. Help business in the state it's it's an honor it would be an unnecessary burden for these people to register as a broker dealer in agents with us in the register in in somewhere where they missed having. I guess the. I'm not trying to be difficult but there's a rule in place and and we're trying to exempt them in so that additionally when we put rules in place as far protection and so now we're trying to exempt them. In. I understand you saying the there is enough safeguards in them but. And this. Usually when somebody says and and I I hate to say this man with some I see this something good for business there can be some nefarious act not stand not saying that you're saying there's anything appears is going to go on but. When we exempt then something goes awry and then next thing you know we're back trying to regulate. At the the first two thousand Bowman so that's what I guess I'm trying to understand it but okay Mister chair I mean you did this no this no on the thing that you can say Mr chair I yield. Unison on this ET this call may wish motion because you look at any like when it just a little you under represent a lot of action to make sure your question is answered before we move on okay all right okay non fine I'm fine. Thank you Representative love I guess I'm curious when you save model language other other states that are adopting this also. yes Sir the the when the national organization and and I I'm not sure that I have a number of how many adopted but the idea is this is something and one as it becomes a model rule provision it's that. Committees within that organization worked on it for some time why likely for a couple years and then so that they get this language just like you know that committee which Representative of probably six or eight states on the committee they come up with this and then the whole body which is in close of. Canadian provinces but all fifty states adopt the model in which and and then it's up to the states like Arkansas this this came about I think it was about three years ago that was adopted. Has finally announced I'm taking representatives lows position people work for a long time for a lot of things so if if it's been in practice and if the act common practice around the nation I understand there be we would hear some issues if there were members I see no further questions and without objection this rule is reviewed and approved thank you thank you. Thank. Item two we have the department of education division of elementary and secondary. Hi folks when you come to the table if you're comfortable in your social distance and you you want to take your mask off so we can hear a little bit better work I'm fine with that. If you would please introduce yourself and you may begin. Thank you Mr chair I don't see there's a microphone there so I scooted over Taylor Dugan I'm with the Arkansas department of education division of elementary and secondary education of the rules I have in front of the committee today or the rules governing the administration of insulin glucagon to students and schools of the only change to these rules was made because of section thirty seven of ACT seven fifty seven of two thousand nineteen the division just copy the words from this act and just incorporated into the them into the rules so that with the rules would be in line with this statute and the other changes that were made to this rule we're just non substantive changing things from the department to the division because the transformation of these rules went through the Arkansas state board of nursing they also went through the state board of education they were released for public comment and public comments were received we also for the statute had to put before the. A committee and August health and welfare and they were approved there and so there's any questions I loved interview entertaining questions on these rules. Members that fee no question so without objection this rule is reviewed and approved thank you thank you. We'll move to item three department of energy and environment. If you would please introduce yourselves you may begin thank you Sir Mike overpaid department of environment. David with the road division would nominal quality. Maybe yes thank you Sir we bring before you today rule twenty three for the hazardous waste management were making changes to the merit of federal requirements. Glad to take any questions. Members any questions. And seeing no question from without objection this rule is reviewed and approved thank you Sir. Item for the part of hell. If you would please introduce yourselves and they will take these individually AB and say. Thank you Mr chair members of the committee on marshy I'm general counsel with the department of health. A Mister I'm Terry Paul with environmental health Richey for the harm health. We have a forty three rules dealing with occupational licensure the first rule is our rule pertaining to septic tank cleaners we have amended this rule pursuant to various occupational licensure acts that were passed in twenty nineteen including three fifteen for twenty six ten eleven ACT eight twenty an ACT nine ninety we had a public hearing in October of twenty nineteen and proceeded with the administrative procedure act and we are here before you all for review and approval. Senator hammer you're recognized for a question thank you I was looking at one comment that individual made. And I just wanna make sure we're on rolled up were a number for right Mr chair pertains septic tank and okay thank you of. A Mister knuckles and son septic service asked a question about grease traps and the concern is that it's against the law to haul it out of the waste district but the waste district won't take it and you all deferred them to a D. E. Q. U. what answer he got out a DQ. I sent hammer I'm not sure. Was it does the responsibility fall under you all or does it fall under eighty Q. agree straps are regulated under not grease traps agreed grease trap hauling it waste is regulated under a DQ. Okay alright thank you so Mr Nichols is in my district he's met with me about this and so what does he do. Well we're certainly I'm happy to follow up with Mister Nichols I think we have his contact information if he has further questions for us but it sounds like the question that he had was more appropriately addressed by eighty Q.. This rule so his question was not pertinent to the rule change. Correct we we try to make sure that everyone at the public hearing they attended the public hearing and we made sure that they understood that we were there to talk about the occupational licensure acts. Okay could somebody get back to me with what we're gonna do Mr knuckles certainly it seems like these in an impossible position there as well as others in that area okay okay this. Thank you Mr just of the back on what you're talking about this is what happens in government so many times well it's not our silo. In when you're in business and you're trying to deal with government run your business it it it doesn't matter so if this needs to be hailed I realized what you're saying maybe just procedures. But if there's something that that this is causing a problem with and we can get to the agencies together for holding this up until we get some kind of answer. Well I can assure you that we will contact Mr knuckles we've got the contact information we've and have at at. AS hearing transcript and so we can go back we got the contact information we can contact him today and I can assure you that that will happen. And the other problem Mr Nichols I don't know it's just one is paying attention right. There are many of the people out here in the. Six seven days a week and and they don't have access where that we are there access so while I appreciate what you're agency has to the if this needs for first up I don't see this being critical Tom was is it. Mr. amenable to that to amend contacting him doesn't resolve the problem. We need to have a resolution to this I would just hope we lease get answered by Friday if we could do that thank you okay can can we hold the. Okay we're going we like to hold this can you just would you mind just withdrawing it and I think if you'll get back to me by Friday I think there's a way we can bring it up on Friday and maybe move it forward on Friday if we have some resolution to this but I think this we're probably hearing from Mr knuckles but that would be a an issue for others to so would you mind can you just withdrawn at the present time certainly Mr chair okay. And now. Senator hammer do you have a question on this. Okay Senator hammer thank you I'm a flipped over the page to legal authority in here's the here's a comment the department of health has authority to license septic tank cleaners and to promulgate rules necessary for the administration of its duties. At that point do you delegate the responsibility for punitive damages or punitive actions against someone who this rule would affect over to eighty Q.. No Sir it what's covered in our role and I'm not an attorney but what's covered in our rule is sector ge and that application of sept itch grease traps in grease trap pumping is covered not pumping but is covered disposal is covered under eighty cues roles. Okay would make more sense at all this week should be. Transferred over AT queue so you all are having to carry the conversation that they're expected to enforce or not that let her down the wrong way well there is an another weirdness to this is that a lot of people with these trucks can I think I said this in the last committee but a lot of these people with these proper trucks can I you obviously point Greece or shifted or our paper waste I me now four party waste and when they co mingle the is when the problem arises and they're not property disposed of so there as I said last time this dish does need some. overall the rule needs some tweaks for sure. Besides what's being proposed in this rule change or some additional thank you all want to work on because we don't want we don't want the honey wagons confused with degrees wagons well that's correct and that is pretty much the truth okay all right so we can work on that the future thank you Sir. Senator Hendren. Thank you Mr chair and I just wanna make sure I understand what we're doing here because if it if I do I think I'm a little bit uncomfortable with it so what you're telling me is the real that's before us has nothing to do with the grease traps or the or the situation that the chairman's talking about is that correct. That's correct we do not have authority over the strap waste disposal and pumping and again I I understand we represent our constituents and we have a duty to do that but holding up of rule that has nothing to do with an issue and I have no idea what the issue with the constituent is. But using this legislative body to pressure somebody to do something for a constituent caused me a little bit of discomfort so you've agreed to withdraw it until Friday and again if eighty Q. wants to work it out with the constituent that's fine. But I'll have more to say Friday of that's the kind of stuff we're gonna do is hold up things that have nothing to do with the issue in order to try to get something resolved whether it's right or it's wrong I just I just think that's not the way we should be doing business. Point taken have. Hi. Valid point now that grounding we need to I need to consider the. Urban. Yes I think along the same lines of what's already been said by actually Senator hammer and senator Hendren I was just very confused because we were talking about septic tanks and grease traps and so at I'm the same boat I was can I'm confused I understand he has an issue but I'm not sure if it's the issue with this rule or if it's with AT Q. and some just confuse a valid point occur okay thank you. Senator rice you have a comment on that. Man I'm I tend to agree with the points that were made that if this rule is separate from what we're talking about we need to find a different mechanism to address Mr Nichols issues. Go ahead Senator roster I did not ask you to be held us and I hope we could work things out by Friday which we do regularly. And and I would just say this. We use this process. More than what's been admitted to far constituents if week see a problem come in and I again I don't understand all the problem either but before we put rules in place that are not I am only necessary let's understand. Because I can prove over and over again that there are are unintended consequences in rules that we do. Own business and and when you have to live with these things out there let's let's try to get him right on the from the and again some of this is just because I don't have full knowledge of this but I I will to find out so I'm not asking for to be hailed. five find out sent by Friday I might asset on Friday thanks for clarification Mister. Thank you. I'm inclined to go ahead and pass the rule of I don't know hearing the objections so without objection this rule is reviewed and approved thank you but I would appreciate if you could get with those folks and get back to us on before Friday's meeting certainly will data thank you. Moving to the next item be. Thank you Mr chair at our next rules the plumbers occupational licensure rules we also amended those rules by the acts that were passed in twenty nineteen including three fifteen for twenty six ten eleven eight twenty and nine ninety happy to take any questions. Members Adam any questions on this so without objection this route rule is reviewed and approved an item city thank you Mr chair a similar revisions to the our water operator licensing rules amending pursuant to the acts that were passed in twenty nineteen including three fifteen for twenty six ten eleven eight twenty and ACT nine ninety. Member seeing no question okay Representative. If you're recognized. Thank you so I yes because we we just sent you nine after a few axle exactly just give me a few things of what we're doing because I'm not familiar with nine ninety because I'm getting calls and questions about that and we can deal with that but what we what actually are we doing with with the other extent we passed socking can be a get up to speed certainly represent level at three fifteen was the act that remove the word regulation from all of our rules so once we open up all the rules we will remove that wired ACT four twenty six concerns issuing of temporary or provisional licenses ACT eight twenty concerns occupational licensure of active duty service members returning military veterans and their spouses ACT nine ninety addresses the criminal background concerns in ACT ten eleven concerns and licensing rules when a licenses to be reinstated issued based upon reciprocity catching okay thank you. And member saying no further questions without objection this rule is reviewed and approved thank you. Item five department of health. If you would please introduce yourselves and you may begin. Mister chairman at Gilmore department of health. Richmond. Stephanie Pratt department health for hearing instrument dispensers. And maybe get thank you Mr chairman Spratt is the director of the board of hearing instrument dispensers and she's gonna give you a brief summary of the changes the board is made most of my due to access their clean some fees but should give you a brief summary is. Most of the change thank you. Pushing the federal. As Mr mat said most of the changes are due to language clean up. Such as a axed eight twenty nine ninety ten eleven because we have implemented a reciprocity clause also set up new lines in guidelines and regulations for mobile units and. We have cut several fees across the board it should save renewing Dispenser's each year a hundred twenty five dollars New a dispenser applicants two hundred fifty dollars and in turns three hundred dollars annually. Licensed by reciprocity is listed under article sixteen. That was her. New article along with. Article seventeen licensure for active pickup this will be a place to move closer to the mine along with article seventeen licensure FOR active military duty. We had at that in there too. Comply with act eight eighty eight twenty I believe. also. Article eighteen. Has some language clean up for the the criminal background checks. From at nine ninety. Other than those two new rules and just a bunch of language clean up. Okay members any questions. And seeing no questions and without objection this rule is reviewed and approved thank you thank you Mr chair. Members on item six on a we have a lot of testimony of and. If there's no objection we're gonna move items six back to the end and move on to item seven. By okay with that. Okay then we'll move on to item seven department of Human Services aging and adult. Hello I'm sorry hold on. Okay. A yeah members we're going to get the item six four disconnect we've got a lot of testimony could take quite awhile to not to let the other people testifying first so we have someone from the department of Human. I'm sure let me ask you. Are you saying that you're going to move that item to the end of the agenda. Remove it to. We're going to move it to after item fifteen. We'll bring it up. Well then I mean because. I would then I would object because I would like to go ahead and hear it out because it could take us another hour or so to get to this again and then I had to sit through. How may I want I want to hear item six. Committee will we are so if you want to hear right now yeah I want to hear it now. Okay members will have to take a vote to suspend the rules to move it do I have a motion to suspend the rules. Yes the rules to move it to the end to have a motion. We have a motion the second. No second. Representative Dotson C. second of all in favor of moving it to the indigent SA I. Opposed no hi folks we will hear it now. So we're gonna go to item six. Department of health. If you would please introduce yourselves and you may begin. I'm Anne am very on the executive director of the medical board. Cavenaugh do our represent the medical board is turning. service Simon I am the chairman of the state medical board's. German five a this is a rule a new rule rule forty six dealing with minor surgical procedures including botox and filler injections of this was approved by the governor's office moved to public hearing of the administrative procedure act on July twenty third approved by the board during its regular August meeting feeling does me and told me I'd like to give a little history of why this rule was necessary sure we had received a number of complaints in the past in concert and some concerns from citizens doctors nurses and also from other meds pause and I'll be honest with you most of them were from northwest Arkansas. Hi the nursing board had also received a number of the same issues as well as a cosmetology board so the nursing board the medical board and cosmetology began to meet about five years ago to try to deal with this problem now I will tell you from the medical board perspective if a physician or a physician assistant. Prescribes medication and what we're talking about and fillers and botox is a prescription item you cannot get it all it's not over the counter you have to have someone with prescriptive authority per the D. A. to receive these medicines. A physician who writes this prescription without seeing a patient is already in violation of medical practice act rule two point eight you have to establish a patient physician relationship before you engage in treatment. What we started seeing was initially untrained non medical personnel that were injecting botox and fillers what made it difficult from our perspective is that these items are not on the PD impede the progress prescription drug monitoring program so we can track it the people that were performing these particular procedures wouldn't tell us to their doctor was that was giving them the medication when we sent these because it's a crime to practice medicine without a license in Arkansas when we would send these complaints to the local prosecuting attorneys or the attorney general's office. Their response was theres nothing specific in your act that says that these particular procedures are the practice of mess so in collaboration with the nursing board and cosmetology board we developed a rule which became rule forty six the nursing board has a companion rule that we also fully support and their rule and they're fully in support of our. and I believe that may be at least in my experience first on the nursing board medical board have been on the same page on an item in the spirit of collaboration we also met with the members of the legislature Representative Gonzales Francis met with this on March fifth of this year he outlined some very specific issues he had with the rules are and we change the rule to comply with his concerns I add later date I'd heard that he had some issues with specifically paragraph one of the rule. Dealing with the training so I added in items a through K. A. and under paragraph one to come to comply with that concern and those are pretty much mirrored from the in the nursing board rule. Accent of sorry Arkansas code an annotated seventeen dash ninety five two oh two three B. defines the practice of medicine. And this very clearly these types of procedures very clearly fall within the praxis Maddox. this particular rule is a training and education rule and a delegation. It is not a restrictive rule. there's nothing in this rule that would prevent. A medical professional from performing these procedures so long as they're allowed to do these procedures under their. Own practice at so the medical board deals with positions and positions assistance and these this rule would allow those two professionals to perform these duties so long as they're trying. there's been a lot of opposition comments regarding this rule I've heard that it rule thirty one for instance the mention of rule thirty one in this particular act are a rule that is set out in paragraph three would allow on licensed medical assistance to perform these procedures the reason we put physician may delegate to on licensed professionals only those procedures that comply with the provisions of rule thirty one that's specifically in there to basically restate what is already in existence and that's rule thirty one which would not allow medical assistance to perform these duties. so the argument that this rule allows medical assistance to performance is absolutely not true. I have also. Received a letter in correspondence yesterday that was sent alleging that this rule violates Arkansas law in other areas well we reiterate the fact that the governor's office already look at this and approved. they cite Arkansas code annotated seventeen dash ninety five dash to two three. Our as their basis for this being illegal that. Comment and also The comment that it violates ACT eight twenty four of two thousand fifteen are incorrect basically the argument is made by taking out a portion of both the act in a portion of our rule in a portion of the statute and not reading the rest of the sentence but if you read the Representative very clearly complies with Arkansas law. The statement being made that you have to be a specialist to to do the these particular procedures. Is not true it and the act specifically sites that you don't you just have to have the training and again that's what this rules ballots training making sure that if you're going to perform these procedures you have to be trained the argument that this is really just the diagnosing of wrinkles or minor procedures. Is incorrect the side effects and the complications from these procedures can be quite extreme I think you could ask somebody that's had open heart surgery before and they would say well is no it was a no nothing procedure I was in and out and I recovered in a week. A minor deal the for other people would be pretty severe and all the doctor Simon he's here with me talk about the complications of these procedures in a moment The number of complaints that the medical board has received verses the economic impact that would result from these from this rule being passed is also been an issue that's brought up we've had a ballot fifteen complaints over the last four years related to this and those are complaint those aren't the phone calls we receive that we try to run to ground. But the majority of the board complaints that we receive vast majority into the ninety percentile. Involve Restrictions Britain four opioids either they were in the position of the P. a rope to many they didn't write enough or didn't give me what I wanted and then behavioral issues so when you take those complaints out of the picture this one actually rises to the top as as one of the chief complaint we received. the economic impact on first of all I have no idea I have no statistics whatsoever on the number of med spas that are out there we don't regulate med spas we don't regulate nurse practitioners and we don't regulate are in so and we certainly don't Lysons and and regulate unlicensed people that are opening med spas across the state so I've no numbers on the number that are out there. And economic impact however related to a business that is operating illegally quite honestly I would suggestion not really be a concern. the and our end for instance who is out on their own. Injecting fillers and botox into a patient who has never been seen by an A. P. R. in and who has never been seen by a physician. All were ready violates Arkansas law. The problem again is. This rule specifically sets out why it is illegal before we had to relate on rely on two point eight which a lot of the prosecutors that we were sending these two would not prosecute on. So. I understand the. Opposition to this rule in my opinion and based on the comments that I've seen really centers on the economic. Issue. Not necessarily about patient safety. Because it's hard for me to fathom an argument for patient safety is involved where you're arguing against training. And qualifications. If you're qualified in your trained to perform a certain procedure it would naturally flow that patients are gonna be safer. With that I would accept any comments the dock some you're here to talk about the complications if you'd like. Thank you for FOR let me speak on the S. I will tell you first of all I think that if we take out fillers botox or cosmetics and we substituted in anything else if I said would it be it would be a profound economic impact that would be negative if we didn't allow doctors to just one timely prescribe anything else would it be alright if I as a physician set up a clinic as a medical director and said I'm gonna sign a bunch of prescriptions for narcotics or we're gonna give general shots in the clinic or we're gonna give testosterone or we're gonna give ROW seven shots in the clinic and then I put in that clinic an institution an LPN or any other provider that did not have prescriptive authority in the legal right to practice to diagnose prescribe and treat with that be okay with the legislature of I just wrote a bunch of hydrocodone scripts and left them there with that provider or file left a bunch of testosterone injection or demerol injections there and I don't think there would be any opposition by anybody no matter what the economic impact of that was it because that's not a that the patient safety issue. And so my concern with this as a position is if I am prescribing any of those things and I'm doing it properly. It doesn't have any economic impact on me it only has an economic impact on me if what I'm doing is improper and inappropriate and I don't think that if this were not cosmetic that there would really be any discussion I doubt there's anybody here that would vote to allow me to open a general clinic with no provider they're not I may be wrong about that but I suspect that is not what our our is in the best interest of our patients. So that being said. the complications for this thankfully date they are fairly rare but they're definitely reported and if they're not recognized in a timely fashion and addressed within minutes less than hours from in your maximum time window is less than two hours to address these complications. So if you don't recognize the complications and you don't address the complications within that period of time the the complications are extreme and they they can include death because of cerebral infarction they can also include permanent disfigurement most of these are on the face the photographs that did I don't know if they thought those but we Kevin turned them over. Those photographs are taken of an eight PM I did not ask any specifics like the name but the patient gave permission in fact she wanted these used. This is an IBM that was injected by someone who did not have legal authority to prescribe and diagnose and did not recognize the complications and the first photo was taken within thirty minutes of the injection the second photo within I think it was within twenty four hours in the third photo is three months that. And what's impressive about that is how close that comes in to contact with her up. And and this is the and I'll tell you one of the other things that they discuss in some of these letters is have this has such a in a negative impact in rule areas for access to care and that it also is a It is also negatively impacting disproportionately female primary care and OBGYN physicians in rural areas I am a female role family practice physician one of my partners is by talk certified if you get one of these complications particularly for a filler encroaches on the arterial supply to the aha and you don't have a rector of over injection within a very short period of time then that patient has a permanent compromise of their vision and I don't know if any of you all ever seen a red trouble over injection but since one of my partners is certified to do this how we approach the local ophthalmologist before we would do these in our clinic to make sure that he would be willing to give a rector of over injection before we would even do anything like this in our clinic because I'm not comfortable as a physician sticking a needle above the rim of the bone here and going all the way back to the post your word so all these are rare they have to be appropriately addressed in a very timely fashion. That's why it's dangerous to patients if these are given and appropriately complications are not recognized in the photograph that you have the reason the APN in the pitchers started taking the pictures this because she recognized she had a complication the injector did not she thought treatment on her own she very well could have lost her vision permanently not to mention the fact that she still has disfigurement on her face. Now amend patient information is protected she requested that we use those pictures and and that's why you have them available to see I'm happy to answer any questions that you have about it but my first concern is chairman of the medical board is patient protection that's our charge on the medical board is is patient safety first. And and that's why I'm here today so if you have any other questions I'm happy to answer on that out of respect for your time I don't I don't want to go over time. Are you all ready for questions we have several lined up. Senator hammer you're first you're recognized. Thank you Mr chair and I just want to clarify this is driven by rule is not as result of legislative action correct. Correct K. and I'd like to. You mention about the number complaints and I get off line with you but I'd like to see the number of complaints and I'd like to see in broken out by the total number of complaints against the number of cases performed in Arkansas and I'd like to see the complaints by occupation whether it's against a P. R. and doctors are in some just give you heads up when I ask you for that because if you're gonna use that as part of your argument for the rule I want to see specifics as to the number of complaints that were given the third thing is if you started this five years ago which involved at least two maybe maybe one or two general sessions why are you coming straight to rules instead of going to the subject matter committee like public health on such a weighty matter as this that were expected to make a decision within thirty minutes to an hour. Because this is the rule process in it was it took five years I wouldn't say it once the rule started taking the fact that the initial meetings began about five years ago but the the rule started taking shape maybe about a year year and a half ago so. It just takes time to collect the information and and and get a rule that because what has what we'll do is look around other states so not to reinvent the wheel to but the medical board according to statute has the authority to pass rules to define the practice medicine and to find the The illegal practice of medicine and this again was just a a part of medicine that is already been dealt with it regulation two point eight but it fell in the cracks as far as on license and again this started with unlicensed people who were. Perform these procedures they they were neither neither nurses nor doctors and that's where it started and it ended up with the collaboration of all three boards because all three of us from getting those complaints. Okay and how long did the governor's office have this and how long did they review it before you brought it to us I submitted it in the fall I don't know the truth we don't know the exact day I submitted it but it was in the fall of last year and they approved it then we re worked it in and they approved it again and then in the spring about eight make Marjorie for okay and. With. Would you be opposed. To this going back to a subject or would you be opposed to sending this to the subject matter committee like public health for more thorough debate or what's the consequences of delaying this so it could go to subject matter committee and then come back to rules well I again I think the consequences is that the number of times this comes up is has been increased So I get calls so when we talk about complaints complaints from our board are generally written emails that initiate some investigation I can't give you an exact figure on the number of calls I mean I've gotten calls from patients and then I worked they ask questions about will tell me about the complaint process what's involved. When they learn that they may have to testify on the back wall when they when they learn that they have to be involved potentially in the process they will back off so those don't really elevate to a complaint. they just back off and go away a lot of the initial concerns I received were from I mean quite candidly I think from competing spa center via tattle tailing on each other but that so that those were really complaints those work those initiated a letter for me to the. spas asking them you know who your medical director is just sort of explain to me what what you're doing I would say the line share of those went unanswered. the ones that did answer I did actually get a call from one who sees operations after after the letter but it's kind of hard to put a pen and a exact number but we can get you the compliance okay last question how many cases of litigation of been initiated over the last five years that you started working on this. Where somebody issued their sue the individual that's operating in a legal manner. To my knowledge an actual circuit court lawsuit yes Sir none that I'm aware of medical board has brought for cases in from the board regarding physicians. were medical directors of medical spas that had no in when when we investigated they had they were just name medical director they had no training or expertise at all in these procedures or they were so remote meaning like one of them was in Russellville but the spot was in phase. And we learned that he was only going to the medical spa once a month. I mean he's not seeing any patients he just review in charge that's a violation of two point eight and I believe that from what I've. I heard that happens a lot we just there's no way to track it because like I said the PMP doesn't doesn't. Track this topic this type of prescription or thank you Mr. So just to clarify for may so you've been dealing with this for five years but you don't think it's appropriate to send it to us to public health and wait another month. Well I would say it's I don't think it's appropriate I'm not sure it's in essence or you're not willing you don't want to do that. Amend just I'm just asking yeah I mean I waited five years but if it's too long to wait to let go to public health is what I thought I heard you say well I don't I don't really see the necessity okay by Representative Dotson. Thank you Mr chair Several my questions kind of got answered but I guess how long the current providers of this been able to operate under existing the existing laws or rules. The current I'm sorry I missed the first the current I mean this this seems to be kind of a major change affecting a lot of people how long have the current providers of the services been able operate under the status quo as it currently exists I have no way of knowing that. So what you're saying is there's been no change for five years ten years fifteen twenty years well I wouldn't go back that far being botox's kind of become invoke over the last you know ten years but as far as who's doing them that's kind of where this all turns on. We don't know because people don't report botox prescriptions there's no way to track that so when we discover that there is a clinic that is using botox or fillers we will investigate that and find out who the provider is who's prescribing it and then are they actually seeing these patients and what we have found some more some are having a position or an A. P. R. in. meet with the patient and then and then they can delegate that lot of them are not so I mean it's been the status quo operation for at least the last decade according to what I'm understanding from what you just said So you and you've had fifteen complaints of the last four years how many of those were at what was the outcome of those really substantiated complaints or with it I mean I can make I can get you fifteen complaints the next twenty four hours if I really try please do. I wouldn't say they're not substantiated the problem is tracking it down and and finding out who actually is prescribed well I mean I guess the question is though of the fifteen complaints you've had over the last four years. What were the outcomes of those complaints were they actually legitimate complaints or they just somebody didn't like the treatment or they I mean you gave us some pictures here that that might be a substantial complaint that somebody turned in yeah I would say all of them were substantial matter comment on this I think part of the confusion here is and and this my Speaker represent senator hammer's ACT question also as far as the complaints and the number of complaints you know this rule deals with people who are not licensed to do this that are doing it so there's no licensure board to complain to on someone who does not have a license we regulate only physicians and P. A.'s as far as people with prescriptive authority so if someone who is on licensed is doing something and we receive that complaint we have no legal recourse to do anything with that complaint other than turn it over to the local prosecuting attorney's office or possibly the AG's office depending on what the appropriate jurisdiction might be some by this rule you're creating a license the note that you wouldn't know as we're not be reading a license what we're what we're doing what we run into is that this is a and and this is what the other boards have run into these are people who do not have a license they're not licensed by the medical board some of them are not licensed by the nursing board or they're acting outside of the scope of practice of their license. We get that complaint and because this started in spots not in medical clinics it they're often was no position of record the wrist away for us to trace them so when we got these complaints and they're not licensees we have to turn them over to the law enforcement investigative branch should that would determine whether or not they were practicing medicine without a license and the feedback would that we would get was you can't do anything about this because it and we tracked complaint against positions okay a or P. A.'s are licensees basically. So if if someone says Joe Smith is doing injections and he's not are licensee we have to forward that on to another agency that's not a complaint against one of our licensees so many of the the concerns that people might have about this or not reported to any agency because these people are not licensed when you try to turn it over to law enforcement they say you don't have anything in your medical practices act that defined this is the practice of medicine therefore we can't charge them with practicing medicine without a license so this seems to me is if you've identified this is a problem that may be an on going problem that's lasted for the last. For five years according to what you're saying at least maybe ten have you ever filed legislation on this have you ever brought this up before legislative committee before this meeting today have you. Brought to public health have you tried to get it to the session now we just follow the administrative procedure act okay so. This is such a major concern that you've never gone through the legislative process before today just going through the administrative procedures ACT to create a rule when most of us are not in session and are not necessarily paying attention this I mean this is a subcommittee of a legislative body that is dealing with this not the entire legislature that's going to be affecting a ton of people across the state. Well the the read this is the practice medicine I've never heard anybody yet. That did not say that this was the practice of medicine I've never heard that argument made yet. And this the statutes in existing now give the medical board the authority to regulate the practices mess. Truthfully when we started this. It didn't seem like that big of an issue just training it is just education there are no restrictions in this act in this rule none. The only people that are affected financially by this rule. Are the people that are acting outside the scope of their own practice act that's it or acting illegally they have no training and they're not license any but the people that are doing what they should have been doing under regulation two point eight from a physician standpoint who were properly delegated this procedure and the authority to perform these procedures are ends. This has no effect on them. None whatsoever. There seems to be production we yes we have a lot of people in the queue an awful prior come back to this or do you mind did you want to respond. No circle okay thank. Is that seat forty six is that Representative Gonzalez. You're recognized thank you Mr chair of first I'd like to get it out there that I did meet with Mr o'dwyer about this rule earlier in the year and some of the concerns that I had were met not all of them so I was never in agrees with this rule completely as he stated so that was that was not correct what it still the committee and I believe some calls were made last night to that effect as well so I just want that out there on public. Record that I was I have not been in agreements with this rule The search continue on from there does this being a prescription not make it by nature of practice of medicine. Yes okay so. That's that's what I regulate the practice of medicine correct so. They are practicing medicine without. A license correct. So I don't see how that. Can't be prosecuted there is a crime to go to practice medicine without a line stand that but you said that they can't prosecuted because I can't prove it's practice medicine because it's not defined as practice of medicine by being a. Prescription that makes the practice of of medicine so why can't they prosecute on the I had I'm not the pricey turning specifically in Washington County I was just told that it's our existing rules and regulations the statutes that we work under we're not specific enough to convey to include these meds office because they were running into people that did not have a license of any kind. And and that was the issue and that sort of what started prompting us coming up with this rule so me by what you're saying is you would have to go through and disk and and describe every medication as the practice of medicine you would have to outline it specifically in your statute that now not necessarily what we started with that but that's what you're doing with this well we're also with this we are say look if you're going to perform these procedures and you're going to delegate this to an are in you have to be trained you in other words you can't delegate you and I could not delegate to someone Hey here's how you do a heart bypass because we're not doctors. Doctors tend to specialize in certain areas or you'll have a general practitioner that does a lot of different things but it's it became pretty clear we started investigating a lot of these we had a lot of our ends that were being delegated this procedure on how to do this by a physician who had never been trained could never dealt with botox or fillers may not have had this training since medical school and when we started bringing these doctors in front of the board asked you know tells about the complications that occur with this filler one in particular had no idea. one one physician didn't even know what the training of the army and he was delegate is that one of the one of the positions couldn't even see tells her name. That was that began to kind of shine a light on not just the on licensed people that really started this process but we had a lot of physicians out there who were just signing off on scripts and saying here go do this okay so so what did you do with those physicians who were doing that because they were. Basically loaning other medical license to. Someone who didn't have authority to prescribe or object so what did what did the medical board do with those positions we already have authority to address those so what would you do about it well I would say that we called them before board. And and many of them were disciplined some of them came before board and said yes here Marcia tickets here my years of experience here's my training and we said what you're doing is appropriate thank you very much but if there was any question and they were our licensee whether they were a position or PA we called them up before board to explain to us exactly what was going on. So. Larry actions have been taken against the yes and we can regulate our licensees and this does not despite all the confusion and I've had multiple calls from positions about this and some from P. eighties and some nurse practitioners this does not take away or in any way regulate or change the ability of someone who has prescriptive authority to do the. This only affects people who do not have prescriptive authority. Just like they couldn't prescribe anything else. So in section and six B. of the rule it does affect that because it is saying what positions can and cannot collaborate with an A. P. R. in eighty are in scanned have prescriptive authority so that at absolutely does regulate actually within regular within with respect no it does not it hasn't war it sets out what training you have to have we don't licensed nurse practitioners I understand that we don't we don't we don't license are in that's a nursing board. What we do regular physicians and so what we did say and look out the in kind of in response to what doctor silence in the I think there is a a a degree of confusion about what can and can't be done as it relates to these procedures the four that were in front of the board one was for laser but kind of in the same vein. We were not heavy handed with them they didn't lose their license they didn't lose their ability to continue to practice what we found is a lot of the national companies that do this med spas and things and there are a lot of independent met spas in Arkansas that some of our more nationally based. They are sometimes will seek out doctors who have been in trouble because they're easier to get them they've what they've been knocked off the insurance panels and those of the doctors that kind of targets a to the doctors had had significant issues with the board. They still were allowed to practice medicine the board just said you can't be omits Bob rector anymore. The consolidated several in the case and I'll get back into I need to do it thank you. Representative shepherd you're recognized. Thank you Mr chairman and if the chairman would indulge me I'm gonna have to step out here in a few minutes to take a call so if I could have just two or three questions G. very quickly and let me just say. As I have reviewed this I haven't really made my mind either way on this issue but I do have a few questions that I'd like some clarification on and and perhaps the. You can help in light me but with regard to this discussion about patient safety the question before this committee today is whether this rule violate state law federal law were legislative intent and which do you agree with that. I agree that that's what it's this body does and with regard to the implication that this rule would have as I understand it from from your testimony today that there are physicians that perform these procedures there are nurse practitioners perform these procedures and then there are other individuals that are under that may or may not be affiliated with one of those groups that are performing these procedures is that correct our internal out to do these under proper delegation and the delegation comes from a from a from a position from the prescribing of someone with prescriptive authority and so the with regard to With regard to the fact that you've said the prosecutors are not willing to prosecute or have not prosecuted certain individuals. This is just a rule this this would only apply to those individuals are licensed under the medical practices act of war the state board of nursing with their companion rule would you agree with that I'll. The reason is because one of the property as to the licensee's yes right with regard to prosecuting attorneys no because the prosecutors were. their problem was sifting through the medical practices act trying to seat trying to find something that said botox is the practice medicine or filler for the practice and the in when they can find that they just said well look I I think they are practicing medicine but I'm and we're not going to pursue this but it but you would agree that this rule does not have the force of law as to unlicensed individuals correct absolutely I mean if if I were prosecuted for the practice of medicine you can bring in the the rules as evidence against me but that does not have the for I could not be I would have to be convicted under a state statute correct and right now the statute I believe is part of medical practices act is basically an individual who is on license to is practicing medicine which takes us back to the definition that that you've alluded to and I guess the ultimately getting back to what I think the standard we have and what I'm trying to wrap my arms around is it appears to me that the real question would be whether this rule conflicts with. the bill that was passed back in two thousand and seventeen I believe. Fifteen. Which is ACT eight twenty four and I've I've read through this over and over again. As to as to that those unlicensed individuals. I'm not aware of anything in the law that would that would necessarily prohibit you would that has any bearing as to this rule as to unlicensed individuals. It appears to me when we're talking about a advanced practice registered nurse we've defined that they can have a collaborative agreement with other individuals with a doctor who has training in scope specialty or expertise to that of the advanced practice registered nurse on file with the state board of nursing. Am I wrong it appears to me that this rule would require actually goes beyond what that law requires and if not I'd like to hear just clarification as to that because at least for me that that to me is the. Critical issue in my mind as to whether this is something that we should or shouldn't allow to move for a and I I would tell you absolutely does not conflict with that law and fact we track the language in the act. we don't use practice practice compare herbal we've training specialty or expertise. It's exactly what's in our rule. And this is also a a regulation or rule written with a sister board with the board of nursing this is not something that the medical board came up with two trying anyway under cut a PM what they tell me where in the rule tell me show me where that it where that is that language if you don't mind AT we say office collaborating with a nurse practitioner provide minor. As that it must be board certified for my show sufficient training clinical experience in baby we say positions may collaborate to provide minor S. that it kind of cosmetic surgery procedures for who with a P. R. in his complete board certification or meets the equivalent requirements four board certification or has completed course specially training is that it medicine as defined by the Arkansas state board of nursing. I mean they're bunch awards in their. None of which good flicks with ACT eight twenty four. So it's your testimony that. If the and as I read this a a physician with a collaborative practice agreement with a nurse with an advanced practice nurse. You believe this rule complies with that provision no doubt. What about the this section one not have not have some bearing on this. Section one of the rule yes are you talking about the listed. Training. Yes. That I pulled off the nursing board rule. Well I'm I'm not concerned about the nursing those are pretty basic I'm just a basic Requirements that you have to know and they're really they're not specially they're not real specialized. Okay thank you Mr chairman. Six nineteen Representative garner's at you. You're recognized thank you very much I'm just a little bit of background I am a nurse practitioner my husband's a physician my sense physician Myers there my kids got parents of god's godfather is a plastic surgeon and one of the things he talks about a lot is the fact that he fixes a lot of plastic surgery issues that a lot of these things especially fillers have hi side effects and and a lot of side effects that may or may not be due to the surgeon or or their their skill set but just the fact that there are lots of of Problems with those types of surgeries but I'm getting a lot of contact from other physicians who used botox that have nothing to do with cosmetic surgery and so I mean the. And you talk about cosmetic and plastics and facial plastics but or learn colleges neurosurgeons orthopedist OBGYN ophthalmologists they all use botox and they were even included in. In this discussion many of them said that they never even heard of it until recently and so it would be nice I think if we had some of those folks at the table when they were talking about this kind of of issue did you have did you have these other specialist at the table besides plastic surgeons this sounds like a this just in reading sounds like a turf war basically four and a scope of practice and and I agree with some of my other colleagues is that this body should not be looking at scope of practice that it's number I'm sorry it's not a scope of practice and we did have other physicians involved I'm a family practice physician one of the other board one of the other board members they did a lot of the heavy lifting on this rule is an OBGYN and we recognize that all specialties use this including urologist they use botox's well family practice does neurology does there are oral surgeons to I mean there's almost no specialty the does not have some use for by the talks now and so the reason these specific ones were included was because that is pretty standard in their residency training to get this or is in some of the other specialties it's not standard in the residency training to get it so that's one there is an order that says or show sufficient training so you could go to continuing education courses to get it you don't even have to be board certified to use it based on the rule forty six you at a general practitioner that has appropriate training and experience can do this there's no limitation on it. But if you took someone who just came out of and the anti residency and they put in a spa and we got a complaint about that particular facility and then they came before the medical board and we said. Doctor what your training and they said I just graduated from residency I have appropriate training and here's my graduation and and how what was trained then they would be finish they wouldn't have to show anything else so what's included in this are the ones that are normally train during the residency program and some of these roads and some of the doctors that use this for neurology urology a lot of the others have special is that are not listed here actually botox wasn't even available when they did the residency training so just like anything else that new came out after you finish to residency training you would have to get some sort of training on it to know how to use it appropriately. So that's what the big four in there is for it it in cops is pretty much any physician for PA if they have had that extra training and they're competent to use it. Hello Mister. I guess this you keep talking about spas and sponsons buys and if that's the issue that maybe we need to look at spas but. Like I said I've had physicians from all over the state calling me saying you know they've been doing this forever and you know doctor sign might. Disagree with you about the plastic surgery that we do and in T. hat back so I'm just confused about what this is exactly and where the big problems are and why we're not looking at the licensure issues that that Representative Gonzales is talking about as opposed to scope of practice. I don't see this is a scope of practice issue at all because it is specifically does not touch the scope of practice for anyone who has their own prescriptive authority and I've had multiple calls from physicians whether they did in their office their main office or were they had some satellite you know medical spa type situation set up I've had multiple calls every call that that I have taken and I have spoken with the physician personally on and gone through and apparently there were some blast email sent out with a lot of misinformation and then that got a lot of people start at that every every physician eight PM or PA that I have talked to about it has either had absolutely no problems with it after I finish talking to them or their concerns were decreased to the point that they no longer and some of them even offer to withdraw the complaint letters that they had felt pretty or not the complaint letters but the comment letters during the open public comment form because they were they had misunderstood what was said here there is a lot of misinformation about this. Thank you Mr thank you. Sixty nine Representative gray is that you yes you're recognized thank you Mr chair so I have so many questions saddest I'm over here how trying to figure out where to start with this One of the things you is surgery to find anywhere else in statute or regulation. It's defined as is the practice pardon partly as practice medicine but the botox typically now. S. about surgeries surgery specifically designed in statute or regulation. Because what I'm afraid we're doing here is we're actually defining surgery in this regulation are in this rule that's kinda go in through the administrative process instead of the it's a scope of practice issue in my opinion and I am on public health and I've been here you know five years five and half years as long as you say you've been looking at this and also ask you you don't you are defining surgeries any procedure our H. human tissue is cut altered or otherwise infiltrated by mechanical means what about injections as far as I I get a steroid shot twice a year that now counts as surgery and what about the tattoo I want to get that would be surgery do we plan to regulate that as well and well there be a forthcoming rule on that body piercings that infiltrates I think you're opening up a can of worms with this. In my opinion. No Way or you look for that. Local practices act further definition of surgery and in Arkansas we give a license to do medicine surgery for positions so there is partial licensure we don't have a surgery Lysons and I'm medical medicine license you're right you have a license for medicine and surgery in that specifically with the license is entitled. And some of the other things that you mentions like the the tech to the piercing those people are not our licensees so we would not be regulating those that should be regulated by their appropriate licensure boards not by the state medical board and I but I think that takes as a by exactly back to Speaker shepherd's point in that you were only regulating your licensees you already have the ability and the authority to do that the people that you say that you have the most issues with or those that you do not regulate this does nothing to fix that. Well it actually does help to fix that in part because if a position you to have a punishment for crime have to define what's the crime first and if we have a we have no regulation on this and we have a physician who who orders any medication whether that botox and filler and narcotic it doesn't matter what it is if they order any injectable and then they give that to someone else who is not. appropriately licensed in trying to use it then we do have the position somewhat we we can get the position for that but we can do nothing to the person that they gave it to and we can't get the prosecuting attorneys to do anything to those people because we have not defined in here that what they did was something that was wrong. I still believe that their licensing so this does nothing to those that are not licensed but their respective licensing boards should be able to say whether they are practicing within their scope. So what you were doing by doing this is changing scope so what you're saying is if they cannot do anything now after this they will be able to you are a alter your altering their scope of practice and it needs to go through the General Assembly session. Well I respectfully we're not changing anyone scope of practice tell me why that's what that's what everyone keeps asking you tell me why you say I'll emitting or expanding anyone scope of practice that doesn't already exist this is very limiting no it's really it doesn't limit anything and if so long as you're trying that me that's all we're saying in the reason this came about kind of go back to the history a little bit. It started with meds pause and it started with unlicensed this has nothing I don't want anything about unlicensed anybody okay as doesn't touch again when we started doing a little more digging and then we started realizing that there was a lot of confusion related to this particular subset of of medicine of this botox and fillers and whether or not and it's specifically the delegation of those particular procedures and so we found that of physicians and and other professionals who have prescriptive authority we're delegating these procedures to people that had no training who the physician or the prescriptive authority licensee themselves had no training to do and that's what this addresses so I want to get back to your original question about what the practice acts as a defines practice of medicine before performing any this is by statute seventeen ninety five two oh two performing any kind of surgical operation upon a human being. A goes on state it also includes suggesting recommending prescribing or administering any form of treatment operation or healing for the intended pally ation relieve or cure of any physical or mental disease ailment injury condition or defect of any person with the intention of receiving either directly or indirectly any fee to get the conversation whatsoever. Okay so this does is is take this area that was very confusing defines what it is. Finds what training you have to have you've got the training far away you go do it. So I work at what river health systems and everyone hears me say that all the time and one of the things I do is I I'm the director for our surgery clinic and I have multiple surgeons that I work with and one of them actually is very against this rule and I mean if he feels like it you are you're telling him what he can and cannot do he is licensed to perform surgery in the state of Arkansas and you are defining it with botox and he can do the rye six surgery which is much more dangerous much more invasive yet I see nothing in our regulations saying that he has to be trained in the rising surgery I guess I'm having an issue that I have lots of issues but obviously I write lots of issues outside of this we we we realize and. If the chair will indulge me one more thing is I was a co sponsor on the act that you told my Speaker that you absolutely were not violating this goes against my in the the very intent of me and Representative audits legislation are intense back in two thousand fifteen was essentially nurse practitioners are practicing medicine on a daily basis I am and we have a lot of nurse practitioners in rural areas who were having a hard time finding collaborative practice agreements with people that practice exactly like they did I feel that this is very limiting. It does not meet the intent of our legislation what we said was scope specialty or expertise to that of the advanced practice advanced practice registered nurse on file with the Arkansas state board of nursing currently there is nothing on file with the state board of nursing that says whether or not they are trained in botox therefore. This violates the intent of what I of what we wrote in two thousand fifteen. But there's also nothing that says they're trained in other areas that's correct which means they should be able to collaborate with any physician that they deem fit that was I wrong as they have similar training that that our intent in scope specialty or expertise and you specifically added training I'm what's in our rule and I'm going to throw in here it's over scope specialty for training what you are doing is defining this to specific training. Thank you Representative gray saying she disagrees I've I think that's what I'm saying that is that this goes against the intent of our legislative know what your intent leading right okay that's all for now the welcome I'll get back in the queue thank you. Senator Irvin you're recognized thank you I'm I I I I think just when this is handed out in your testimony you said that you added items a three K. E. is that correct per to comply with Representative Gonzalez's concerns is that correct that was mentioned both as Speaker shepherd but that was added per request that correct yes okay so eight three K. with added to per request from Representative Gonzalez alright and was also the line on the back on BBC six C. six B. with that underlined unless best unless specifically authorized by the respective practice acts or rules was that also a request that was added by Representative Gonzalez yes correct okay so I would disagree with my colleagues on the house side and that and it does follow legislative intent because you just read it. You just read the legislation from the medical practices act which gives you the authority to do what you're doing that follows legislative intent in including the language from the twenty fifteen act that has the orders in that language that refers to training you reflected that with your orders in training and suffered mesh so or motion sufficient training and clinical experience so it's consistent with the twenty fifteen act because you include it for if you had included and then it probably would have conflicted with that so respectfully disagree completely with my colleagues on that because what you're doing is you're following in state law your following federal law you're trying to comply with what the FDA I've I've read this and the nursing board is bringing a companion rule is that correct so this will be consistent with what we're trying to. To to clearly define because as I understand it we had one physician he was so badly duped. That they voluntarily surrendered or license that correct I thank you voluntarily withdrew his directorship of US of a so he voluntarily signed as he resigned because he he writes okay because he saw. The conflict in this I have people I've talked about with this under this is been something brewing I mean I know you've had lots of discussion back since March with people that are members of the legislature which I appreciate but I would also ask you so a physician who is trained can train our mentor other doctors and nurses that are also trained at potentially no cost is that correct yes so in order to do this it worked with this is this to me is continuing medical education that's very different than scope of practice training license training education and delegation is not scope of practice that is that is how we practice our craft so in response I mean I was the one that did the you know works with the the tattoo the reason why we actually changed it to body modification instead of tattooing with and we clearly defined in that was that and it needed clear definition was because when you insert things under the skin that was beyond what a tattoo artist should be doing because they do not have knowledge of the nerve endings and the subdural Issues under the skin and so they themselves said inserting ball bearings and things like that and horns or whatever that's not something that we are able to do so again it was clearly defining what they were able to do and so I I wanted to ask you because I think it's important that we have some clear clarity and definition of how this is going about I've spoken with with members of the medical board and on that medical board you have entities you have family practice you have a whole degree of subspecialties that correct yes okay and and I think finally what I would just say is. You I think your comparison with what you said about hydrocodone. Is incredibly important. The last thing that I would like to see is as set a precedence where you would have a quote medical director of a pain management clinic he would write a prescription for a general. IV injections. And allow someone who's not trained he doesn't even have a license to administer that. That gets is in a real dangerous place in my opinion. So I wish Dodge time if you would elaborate. On that comparison the inmate. Our state medical board doesn't determine what medications require prescriptive authority you know that's done by by a body such as the FDA in the D. eight that is not done by our state medical board botox and these injectable fillers have both been determined to be concerning an act that they require prescriptive authority before they can be administered and where some of the I think the slip with with whether or not it should be something that they could do without a position there came we ran into this with the laser regulation several years ago because some things that are considered because miss to locals are available over the counter some lasers are available over the counter you can go to bed at cosmetics store and buy a home laser for hair removal now you know twenty years ago you couldn't do that so the FDA in the D. E. A. have gone to the to the degree of determining what lasers require prescriptive authority and which ones are available for over the counter use they've done the same thing with the medications that are for constant primarily for cosmetic use not I don't think botox's primarily for cosmetic use the most of the botox that I see prescribes actually probably not for cosmetic use because I'm not in a cosmetic center field so most of the patients that I have the receiving botox from a specialist or getting it for some other problems. they're getting it from the urologist or they're getting it from the neurosurgeon or the neurologist or some other specialty not any of the ones that were listed in here as possible trainings that that would require it that everybody seems so hung up on so to me the fact that it requires a prescription means the it did it requires closer supervision. And unfortunately because it kind of got mixed in with these other things the botox parties in the you know in the early two thousands and things like that this is not something that you play with this is a medication that requires prescriptive authority that was not determined by our state medical board and that's because botox's botulism yes ma'am Sir could you describe why botox we we state botox we think it's you know not something that's. A serious. In a drug Sir can you describe why because I understand I mean I know that it's being used like you said I mean patients that I had had a friend that told me about a friend who had a terrible policy a child who had cerebral palsy and that they were using which is botulism and so describe botulism in which is actually it's a toxin by to talk office and correct and botulism spores occur naturally in the environment if you look on the honey package you know for an pastor as tiny it's is not to give to children under one year of age because of the risk of botulism so it it causes paralysis and that's why it affects wrinkles why they disappear if you have no muscle tone then you don't have wrinkles so when you inject the botulism toxin in small amounts in areas that you don't want to have as much muscle tone so for instance your cerebral palsy patients that have a lot of muscle spasticity then what that does is it relaxes that muscle spasticity so that the child has more range of motion of those joints were told to could be used on adults as well for that the same reason it works FOR migrant it stops muscle spasms that are associated with migraines it also stops the muscles that calls wrinkles whenever you move your facial muscles. But the unintended consequences of it if it's injected improperly or sometimes even if it's properly injected one of the potential consequences is that it can affect not only your vocal cords but your ability to breathe. So at and I think that is why this is the practice of medicine you have different levels and degrees of certification and training is that correct so as as we progress right we have a different levels of training so we're not saying that the collaborating physician has to go back to residency and become board certified and plastic surgery is that correct no ma'am that does not do that this rule says that they have to have sufficient knowledge and training if so what does that mean those that describe what that is what the cost of that might be. And looked it up earlier today the online botox training as a one day training and it cost about seven hundred dollars so we're fighting over a one day online certification course of seven hundred dollars for those books for botox is mean that's what we're fighting about. That's really what we're fighting about. I mean so I I would appreciate as being real clear about that's exactly what we're talking about here so I I don't understand why somebody who could be this position. And be a medical director have the ability we we have do we not have let's talk about long term care. Senator we get number people in there could give a lot of two two hundred laps if you don't have been latitude to many members Mister chair will not stopping your minutes asking letting you know that there are a lot of people in the queue I understand thank you. You could also get that training for free if from a colleague you can get your training from for free from a colleague. Senate and I could just reiterate this kind of gets in the turf guarding question and whether or not a thoracic surgeon can do but they can they can do it now. Is that have to do with whether or not a physician can do it this is a delegation rule. And I think that's kinda getting confused in here. A physician can perform these so the fact that a thoracic surgeon says I read in this rule and it says I can't do this I'm really confused as to where he sees that or she sees that I don't know if you delineated whether he was a male or female this is if if you look at the rule the line above paragraph one the delegation of minors that a cosmetic surgical procedures must comply with the following program then it goes and everything flows from that sentence. What is going on dental practice I'm sorry what which is why it's not scope of practice it's delegation okay delegation if you're going to delegate this you've got to know what you're talking about thank you it's just got public call policy thank you for bringing it forward. Thank you members I've had a number of people comment that they think this needs to go to public health are more vetting however we need to hear a public comment before I can entertain any motion so if you have a question we're going to we have one two three four for more folks to go on this but if we really need to hear public comment today and then at that time all entertain motions. Sure you want to just move no we're gonna we got people in the queue I'm on let them ask their questions if they so choose okay. Representative love. Thank you Mr chair who do you have a list of who signed up for public comment. I do okay are just checking all right so. In this proposal up well let me first start off because I'm not is being gay for in depth as everybody else in here some let me start off with this so. Is it botox is botox surgery. Is it botox surgery could that's already we've been talking about some just trying to figure out yeah I think that's defined in the second paragraph of this rule surgical procedure defined by this board as those surgical procedures would cut I can't I can't hear you all for sorry to far away from me if you look at the second paragraph our charts of minors that a cosmetic surgical procedures do you see that okay so so let me ask you this is this already defined or are we do our work okay so this is not already a fine correct in we are now proposing a rule to define this so. How can I guess I can now see where my colleagues are with the scope of practice but okay all right so we're defined in this now tell me this is. Because our I heard the lady in blue I don't know your name but there's there's of botox certification. You can obtain certification from one of the companies that provide that sales the botulinum toxin you can go to continuing medical education courses that are provided by someone that is in that company or it can be taught by another provider who already knows how to do it so is this right here in number one more stringent or less stringent Dan Dan that certification because I guess if we're talking about botox and just I don't know why we just wouldn't say Hey this certification but now we're defined a surgery we're defining I'm just trying to. It says this may include but is not limited to board certification and core specialties in those core specialties often. Receive that training during the residencies but if you trained in. At any of these occupy sticks are you trained and and ocular plastics and you trying to thirty years ago and botox was not available fillers were not available at that time that would not be something that that most physicians are gonna do without someone saying teaching them about it so the purpose of residency program is to further train you after medical school so it's up to the particular for prescriber to determine what kind of training they think is sufficient and then if there is a complaint or problem and they were to come before the state medical board for us to inquire with their side of that story is we may ask them what was your training in this and I may say I went to an ocular plastics residency or they may say I went to a family practice or did a one year rotating internship I didn't even do a complete residency but this is the training that I've had in this particular procedure okay so then we will get back to but we're adding something to surgery correct we're and something to the definition of surgery with this rule well again with regard to delegation we're defining that because what you're doing what this isn't a scope. You're not expanding or reducing what the licensee can do as far as their particular practice their scope so just saying you if you're going to delegate this to someone you've got to have this experience and training okay so if I to get if we just took out the the this this section above one. How would that impact your rule. Which section referred to the both of the above one. This is my mistake surgical because what it looks like to me. Is there with the we're expanding what surgery surgery a surgical procedures are if it's not already in the room you're saying it's not are in the rule correct now the only deal no it's not it's in the statute that says any surgery okay but what I'm saying is if we took that out. How would that impact your room. Honestly I think it would add to the confusion that already exists on exactly what botox is. And what fillers are. Three the reality of the situation is if we had the ability to track who is prescribing botox and fillers. This probably wouldn't be an issue for the may harm. You just sent the botox was a prescription this and are you saying that we don't have the ability to track that. I don't have the ability to track it it's not on the prescription drug monitoring program is not skates not schedule drug. And that's the only system we have access to where we can track. What is prescribed within winding we just go that route. Because I don't think the prescription drug monitoring program eight deals with schedule medications and this isn't a schedule medication that the FDA is if it is it is a good dangers that we need to. That's whether or not it's a schedule medication is not a state level decision hello thank we're getting a little bit offer were were I'm just are you sure I understand we don't understand something before I I mean I understand where you're go I stay with your stay in it but why it why that particular drug is not monitored by the prescription drug monitoring programs because not schedule medication and whether or not a particular drug is a schedule medication. Is a federal level decision. Okay so we can add that to the PNP PM. Are the I know I'm asking are. the only the only other thing I just I just wanted to talk about was the was the the training to use the Mr chair Ali I will yield and I'm looking for to hand of the testimony thank you thank you. A Representative Gonzalez and forty six you're recognized thank you Mr chair again since my name's been brought up yet again I would like to say I did not request a through gay and section one of this and one thing I did specifically ask for in six B. was to have the international society of aesthetic nurses removed from this completely that's a private organization that were potentially requiring these people to go to and that course. Part of the requirement for you can ever test test for that course. Is that you work with a plastic surgeon oculus plastic surgeon as some other core specialty so that's one reason I specifically asked for that to be removed so again that's statement was not correct Going back to the scope of practice issue here when we redefined surgery. And then you tell oriens and APR ins will understand this is a delegation issue but now you're delegating their and sand that they can perform surgery that's no where in their practice act that they can perform any kind of surgery so there scope would have to be changed to allow for this. Now we specifically stated in there that unless specifically authorized by their respective practice acts or rules. And surgery is not specifically authorized by their practice I delegate. So it absolutely does change to you this can be who who can do these procedures no it doesn't if they can't do it under the rug Iraq this act they can't do it period or they shouldn't be. This is the site essentially what a lot of this is is restating existing law they can't do surgery and if you define this as surgery then they won't be able to do it so it does change who can do these procedures. Respectfully no it doesn't they can't if they can't do it under their own practice act you what this is saying if you cannot delegated to. I thank both of you are locked in on your answer we're saying the same. Okay. You other questions Representative. No thank you. A. Representative gray. Thank you Mr chair BLB kind of quick we've got a letter from a plastic surgeon up in Mountain Home doctor Newman and that he is a page my. My mother had breast cancer and least in her reconstruction so he the of a friend of the family he objects to this mostly based on the adding of cosmetic as a core specialty is cosmetic surgery recognized in the state of Arkansas. I'm sorry I Senate bill is is cosmetic surgery recognized essentially in the state of Arkansas is their licensing board FOR cosmetic surgery so what did we included in the rule. Just a word cosmetic. Yeah but we have fought plastic dermatology ocular plastics those are all. True specialties and right we don't well in the state of Arkansas we don't license we licensed physicians and surgeons we don't license specialties but you do have a number of organizations that that certify particular physician is board certified in particular areas so we list those we just list those as if you've got that that sufficient training for. You can show other training. So you're not locked into those okay no and I realize that I think and I'm just going to his letter here and he is initially says to suggest that a physician must be board certified by non recognize board of such as the a B. CS is to be incredibly incredibly deceitful and potentially harmful to the patients of Arkansas enter the reputation of recognized medical board's and also would would say that. From a legislative perspective and I know from your perspective words mean everything and so we passed this with that cause medic peace in their wording in there I think that opens up and adds them well I mean I let's say this on his letter I can't disagree really with what a second but this rule doesn't say what he say. Is reading it he he's like reading one portion of it and then just stopping and not finishing for my show sufficient training clinical experience in foreign seizures so what I've heard today. Everybody in the room that's asked you questions been wrong everybody that's written you a letters been wrong everyone is wrong it's an when I also looked through your responses and I would is same as the attorney they were your responses essentially and I was trying to find one responses to every single issue was the board doesn't believe that the rule state this position the role adequately protect patients and allows physicians and so I know I'm a beard off of my original questioning but you didn't actually respond to any of the objections all you said was essentially I'm right you're wrong. The Soviet Mr chair I don't you have a question there I'm on public health and I would love to see this go to public health and let us decide if we had at the appropriate time I'll make that motion let us see if this is actually a scope issue thank you thank you we have you ought to get a lot to make that motion there are several. Senator hammer you're recognized thank you Mr chair question to the chair first do you at do you at any point the nursing board has had their title invoked in this conversation but they haven't been to the table yet do you intend to bring them as part of public testimony or where they have a separate slot you we have a public comment of several listed in if they are not part of that public comment and you would like to have them then the chairs very willing to have them come like to have a number one and then number two one question to the presenters please I've I've heard the concern about this procedure in the side effects and we've been given you know graphic pictures which a feel for the patient I'm just right I'm just wondering notice rises to the level that it's as dangerous as you're saying that it is it seems to me and I'm not a doctor not attorney just a layman it seems to me that it minimizes the argument that it could be offered on the online class FOR and I'm not sure where you came up with seven hundred dollars or you know a friend could teach you I'm I'm just wondering why is is able to be done online with the severity of the concerns that you have that it wouldn't require actual hands on training prior to cope ID all of the training was in person and it was one on one procedural training the reason that the training went online was like many other things code precluded a lot of travel especially in certain states and it precluded the ability of in person training in close proximity the other thing is all many state suspended elective procedures and it only became available as an online training after that as opposed to code is not gonna be around forever and sometimes I think it's beginning to be used as a convenient excuse I'm wondering what happens if this rule goes through. And Kobe goes way that are you gonna come back and require that it be done in person or does the rules as you presented in today specifically state that it would have to be done hands on with the option to continue online be an indefinite option. We haven't specified what type of training is required just that they can show sufficient training. Because there are many ways to do that most of the residency training is some of it is reading the textbook reading online reading appropriate medical literature but a lot of it is one on one training you work for the more experienced doctor who showed you this is how you do the procedure and this is just an extension of that a lot of our continuing medical education is an extension of that particularly is new procedures come out laparoscopic surgery wasn't available fifty years ago we didn't make every general surgeon that wanted to laparoscopic appendectomy is go back and completion of the residency to be able to do laparoscopic appendectomy is versus open appendectomy. So there is some base level of knowledge there the you have to be adding to and so there's not a specific requirement of what type of training there's not a specifically requirement that they have a particular certification it's just that if we ask them they need to be able to show with that they have had some training and what idiots and it is appropriate. And we would do the same for anything else if I decided I have no training in neurosurgery but I want to become a neurosurgeon and I have bad outcomes then the board can call me and say call me up before the board and say what made you think you were trying to do this. That's not in the patient's best interest I may have the board called before how many have been called before the board because of improper of botox injections or how many of you held accountable thus far. I don't know off the top of my head how many doctors we've had that we've had correspondence with or phone calls with we have significantly more phone calls then we do written correspondence and we have more written correspondence than we do actual complaint. We have at least fifteen actual complaint. Okay alright thank you Mr. Representative Vaught you're recognized thank you Mr chair so I for one do not appreciate being told that I do not know the intent of a piece of legislation in which I carried I know the intent of that piece of legislation. So the intent was to clear up what was already ninety what you're trying to muddy back just so you kind of understand where I'm set and and so my question is how many how many cases of death have we had due to botox. Are you asking them the why I'm asking you in this state how many have we had. It's not normally tracked by state it's normally tract is an after market reports to the company or to the FDA afterwards and if you'd like me to check their website I'm happy to do that but that's not normally tract specifically according ascetics surgery journal. Just according to them in two thousand and nineteen that was zero death how many deaths have there been to opioids. Just this year sixty nine thousand twenty nine. We have and we wrote legislation that clarified. And I do not appreciate you come in here before us exponentially you Mr Kevin telling me that I do not know the intent of the piece of legislation in which I write. So I do see this as a scope of practice I do not appreciate you down there speak and back to people telling them that it's not a scope of practice when we all agree according to most everybody sitting here but one maybe that it is a scope of practice. So Mr chair I the along with I agree with represented gray at a proper time I would give a motion even. There anything else represent of a. Thank you that concludes all the questions you all if you would to vacate those seats we have some testimony we'll do folks for and against. Thank you for. For. I will go first with us someone speaking for the rule looks like lives with Klaus is that correct. If you would please come forward. And folks in your testimony I would ask if if you have testimony that Cooper is corroborated by a someone going before you if you would keep that limited but you're certainly welcome make the comment you need. So if you would please introduce yourself and then you may give your comment. my name is Lizabeth Klaus I'm an RN and a certified plastic surgery nurse. I have been injecting in the state of Arkansas since the nineties. I have always worked in a plastic surgeon's office which I think is very important because if you have an issue or problem you need someone available that knows what to do how to do it and can help you. I think continuing education is paramount if you're going to work in this field. Things change and just because you learn to do something one year doesn't mean it's going to be the same the next. The incidence of adverse events has increased exponentially in relation to the number of people injecting. I think this is about patient safety and nothing else thank you for your time do you would you mind taking a question I'd be happy to. Senator when you're recognized. Thank you I'm just can you describe your and your registered nurse you said in your certified in my six or trainers plastic surgery nurse could you describe that certification. I started in plastics thirty nineteen eighty nine you had to work in the field of plastic surgery for two years before you can take the test to maintain certification you have to have continuing education every year in your specialty. Okay. And can I ask where you Where you trained to modify as where you trained for nursing yes in Arkansas in a. Thank you. Thank you for comment you're excused. Next we have John Burroughs speaking against the rule. If you would please introduce yourself. Thank you Mr chair sorry thank you Mr chairman John Burris I'm here to speak against the rule. I know that this is an issue where your everything's been said but not everybody said it and so I'm not gonna try to belabor appoint but I'm speaking because. Like many of you have been frustrated in so a lot of you were called by medical board Mister Dwyer the governor's office and we're told that. A like me and sometimes even the were spreading misinformation and I'm here to tell you that that's not the case on the city or publicly until you everything that I will say to you privately because you can accuse me a lot of things some of you have over the years but but you can't accuse me of of spreading misinformation and that is frustrating this rule conflicts with legislative intent into very simple what his Representative Gonzales interpretive garner I think made this a simple point they weave in and out when they're describing this rule and talk about on license people and that's Baltz within go back to talking about or in certifications in there talking about two different things this takes a sledge hammer to an agent. The way the way redefines legislative intent is as the in two ways as Representative Gonzalez said earlier the second sentence of this rule because botox injections surgery. And then they later on say nurses can do it on its face simply read non attorney speak that is a conflict there only explanation is that. The medical board rules cannot apply to nurses therefore it would never be applied therefore it's not applicables therefore you don't know what you're talking about whether or not it can be applied is not the point though the point is that the practices acts as passed by the legislature. An amended often. Says who and who cannot perform surgery the legislature gives doctors the ability to perform surgery it does not give nurses the ability to perform surgery so in this rule says that a procedure is surgery and then says that a nurse can do it it conflicts with state law. In to the second point of Representative grand ball they passed or the legislature passed the sponsor the bill in two thousand fifteen. That unrestricted collaborative agreements and said that and APR and can collaborate. With any licensed physician in the state not does not to be a specialist on restricted in a licensed physician can collaborate with a PRN that was their intent it passed this rule for one procedure. Now says that. Thank thank vague undescribed that's really good for attorneys it's not good for public policy. That long list of things that attorneys have to check box try being a doctor. Reading that and worried about getting a complaint which by the way these boards often leave open for years unresolved. Try reading that understanding out applies to you. The legislature through that bill passed a law they pave the road. In this rule puts up gates and speed bumps all along the way for one specific procedure injections. In those two ways it violence legislative intent and I will close by saying it's in some ways I know how it feels you get people appear that explain you don't know what you're talking about acronym afternoon here some pictures. They use terms like some complaints. You know sometimes people call we have a lot of the complaints there's been a few dozen over the years. Is the name of the complaint and we got a lawyer said you had to freedom of information well it was always a competing position. And then when they wouldn't close the case as we said you have to close these cases of compliance so then they sent letters closing the complaints and to be fair this with the nursing board. Sent letters closing the complaints senator nurses sending we can't find any evidence you violated the roller lawyer scope of practice but don't do it again I mean imagine if you as a legislator getting a letter from the ethics commission saying we can't find evidence that you violate ethics but be sure not violate ethics again. That's the way these boards and commissions treat people sometimes thank you for your intent and they nor plain language and explain it away as if you can't read. So I would ask you to. Either vote against this rule or send it back to the committee or should be study because in the end it's really simple training should be required and a doctor should up to see if a person to prescribe. It's not nearly as complicated as should take five years to solve the problem thank you would you mind taking a few questions yes. Senator hammer. Thank you Mr chair a person. Conflicting comments but then I've heard some what I would interpret as direct accusations of integrity of a person making a comment today I'd like you to give me or if you want to give it now if you have a fresh on top your mind where you have had misinformation. Spoken or credited to you and who did it and if you want to write that gets to me that's fine but you know we have people come in here they're not put under oath they give testimony then we find out later you know maybe there was direct mission tent maybe there is unintentional miss intent but sure adds value to what we do moving forward now be administered wire the medical board told the governor's office of the think the governor's office told you all that there is misinformation I think it varies sometimes people use the word lie sometimes these mysteries but I I think that's where it originated much like today this debate's been going on for a year. Not at the legislative level mind you but behind the scenes and so that I I think that's where it originated. Our thank you Mr. Your term you're recognized thank you and your comments to talked about board in their actions that they are taking in its Fagan house not fair right yes that that and that it's good thing to seek clarification. That is how I see this. I disagree with you I disagree with the comments that have made by my colleagues because I see this as clarification. So that that doesn't occur to people so that were real clear about how things are defined and we're real clear about delegation about training and that were clear about that I see that is a good thing and I I see that your comments. Says say thank you I believe that clarification it's a good thing yes ma'am. So I'm I suppose that confuses me because I appreciate the efforts that were made to try to work with those that were concerned because there are lots of efforts made to work with folks on this issue and this rule that were opposed to it and so I appreciate that and generally we try to do that with one another or not I appreciate the board's doing that I know that the nursing board has a companion rule on this and I know that they are trying to look at this issue together and collaborative lady which I and as well the cosmetology board so each of them respectively deals with their folks and so I guess that's why I'm confused by this whole. Discussion because to me this is about doctors receiving the training the continuing medical education and then appropriately delegating that to people who are also able to do this not to me I'm not trying to do this. And I know that in the past some of the cases that are brought before the medical board would you not agree that that's a problem that if there's somebody from one side of the state to another side of the state that's right in the prescription handed over doesn't know who is getting that prescription and doesn't know what that person is getting the prescription is doing and not signing off on it he's not taking with the patient follow up he's not he doesn't know if that person knows how to do this or not or is regulated to do this or not or license to do this or not do you not see that as a problem yes. Up. I make thank you for the answer the question I see this as trying to address that problem and to me that's about good public policy as a health policy. Yes ma'am I would say that there's an old saying that however you beautiful the strategy you should occasionally look at the results and if the intent was to provide clarity I think this committee shows that it does anything but that and and I think the public policy problems are best solved by the legislative process and that the best solution here would be for the legislature to pass a law that you're where go ahead that clarifies what training should be required for people who do these injections and maybe more specifically define what the role of the doctor is in that but I just think that this is anything but clear and that is a public policy issue that the legislature should address not what I think they've done here slap a label on something by calling surgery botox so they can regulated and I think just common sense says that it's not. But the law says that if it is surgery nurses cannot do it and did you stay here you're representing yes my will know what I have a coalition of doctors nurses A. P. R. ends on our and to came together to oppose this rule and I hired your firm that's correct to combat the farms the medical society and others I'm sorry but I don't. Thank that's a correct statement. Advocates on both sides. The I don't believe that there has been another group hired. On the other side I'm not sure I know that there's just advocates on both sides there could be applicants but there's a difference between an applicant and and hired advocate thank you. Okay Representative Vaught you're recognized thank you Mr chair I'm not sure I'm not sure if this is a question that you can answer for me or not I I just came to me So. If there is a complaint then he decides if that complaint is legitimate or not and then where would that go and then he would be making that decision. Tell me that I would say generally that rest with the board and there and then attorneys and their attorney and so that attorney is the gentleman that was at the table just a minute ago rat yes ma'am the one of the most for decide and if we were going against legislative intent is this correct yes ma'am thank you Sir. Senator hammer you're recognized my question just got answered thank you. Representative gray you're recognized. Thank you Mr chair Start quite Representative Burris I guess that still okay and question back to the intent of the legislation that Representative Vaught and I ran into thousand fifteen the wording says so I just would like your I guess expertise from where you stand both professionally and legislatively when you were in the house training in scope specialty or expertise so I agree with that part two to that of the advanced practice registered nurse on file with the Arkansas state board of nursing. So to my mind to my understanding that the state board of nursing has on file a sensually their license. They're license I don't know what other documentation they have on file I guess so what I'm asking is with this rule they're saying it meets legislative intent but it doesn't meet legislative intent if they have to have something else on file does that make sense I guess what I'm trying to ask you it it does to me and I think it goes to the heart of how this is shifting around law and rule one rag in a way that's more burdensome and whether be scope for training or regulation like you mentioned that's why I think it should be addressed through a regular process of the legislature through all. Thank you. Senator hammer you're recognized. Q. for down the road you take it off. Okay thank you Mr. Up next we have of Mr Curt Clark I don't know if this is the did marker leavened were you here to speak on eleven are on this topic. Check. In the meantime we have doctor. mentally second by saying that correctly. Okay yes come forward you wouldn't. And you are here to speak for the rule. And if you would please introduce yourself and you may begin thank you. Thank you ma'am when you hit the green button in front of you there please. Okay. Well good morning everybody I'm I'm doctor me me Lee I am a board certifies stirred general surgeon I've been in practice for twenty years and I'm married to a plastic surgeon who is also a board certified. Follow about last ten years I've been doing exclusively botox and filler injections and I came here on my own time you know without pay don't have a lobbyist but I want to be a patient advocate and I I know there's a lot of Legality of today's meeting that I'm not comprehending however I want to bring to light that These little injections on not just a simple shots which is I think what most patients the seating and is up to the physicians the F. D. A. S. wells a lawmaker to protect patients because patients don't know anyhow I know Some of you have seen some graphic picture and this is a picture from the aesthetic plastic surgery international society of aesthetic plastic surgery it shows some. The blood flow is being compromised some from the NATO injection which is not an FDA approved procedures so. When non FDA approved the drug including botox cosmetic as well as a jungle feel on. FOR injections date clearly on the side describe how way it could be injected and how much and and is a prescription like someone had mentioned and I'm licensed physicians can order it and E. from someone the rest comes in when the procedures done at and non FDA approved area and that higher risk so injecting of the nose as well as under the eye and you into a smile so. Can go into the vascular you know complex vascular blood vessels and it can do two things it can immediately blocked of us that love to supply to the tissue that is feeding and in some cases when the bloods when the feel they get into the blood vessel it can actually travel and the problem with the traveling is that because it's right in the face it travels directly to the eye and can go up to the brain so that's when a complication of blindness and struck can occur. It is rare and now but the statistics is zero point zero five percent. I have met injector I've been doing this for ten years. According to ray you know I would do about four hundred done locally injection a year and so every five year I will have one of these vascular incidence that's the going rate and I have that one and I'm very properly trained I attend the US CMT classes every year per state law and the state law require of the state board right I required physician to attend twenty hours of CME pertaining to the specialty or what they practice so so the as a decision myself I'm trained and but complications can happen the the most important part about complication is recognizing immediately and so you would see the they could be a flash of the blood vessel being blocked so everything would go dark and pale and they'll come back but if you don't recognize that you're losing the fight blood supply can be cut off and you can lead to permanent damage without within ninety minutes and To revise the consequence we can inject an antidote medication which is also a prescription it is called hyaluronidase it is I medication that you have to mix and then injected into the area to basically flocked to tissue so that it will dissolve the filler I also want to add that some filler and not the solvable so eva inexperience injected choose a filler. That is not reversible. That could be even a bigger problem so eat away there's a lot of steps in taking care of patients on and it's not just the cost medic injection is is a procedure and I knows there's some confusion about what is a surgery. To me when you injecting a filler I considered an implant because it stays and given IMPLAN is placing properly it can get infected not necessary a huge problem but you know it could be a long standing problem can lead to years of inflammation so either way I just kind of want to make sure everybody understand this is not just a simple shot like giving a flu shot or steroid shot wish you doesn't really have a serious consequence anyhow So to me the way to reduce some complication a metallic D. and improve functional outcome is to make sure we avoid a situation so by taking a thorough history Ensure patient hasn't has surgery you know I've seen numerous patient that comes in they have had a skin cancer removed they have had busted their lives when they infant so the vasculature of these patients are altered I would never offer a patient who has busted their lives it lip injections because I don't know whether they have intact Bosco supply that's just me but I know people are less trained may not even ask that question may not even notice this car so training is extremely important because without the proper training you really don't even know what questions to ask and how to prescribe if this patients even a good candidate and so. So I definitely I think it's important that you know they need to be supervising from physician but also the training needs to be part of the the supervising physicians you know qualification as well and once again going to having recognize the problem and not treating it properly. Having the into the available I spoke to the doctor Christian may last night he's a board certified plastic surgeon as well. He has a receive at least for referral some from. Patients in stock car. Mickey and I have seen a referral from patient in Conway so so with you know vascular and complications so these are real you know so then not just in the literature and they are present and and that you know the incidence of these it's going to go up just lately is that because some. The procedure is gaining more popularity and there are just a lot more interest in people offering these injections without really knowing their qualifications so I want to just direct everybody to focus back on patient safety and I really really hope that everybody can come together and and do something that will protect our patients you know and Unfortunately due like someone had mentioned you can't tract how botox and filler I orders because is not a US scheduled substance and and I honestly don't know how they obtained at botox party because I never really heard of a doctor being present in the botox party so should there be a complication what's going to happen you know so I just want to bring those it you know to everybody's attention because you may not know all that going on but this is what I do every day and and I will be glad to answer any questions. Senator Irvin you're recognized thank you just present you being here and The complications that have come to you are are you happen to reverse them or is it within the time frame to be able to do that and you also commented that this is an implant and I wanted to because I wanted to to allow operate on why you believe this is an implant which which is very different than. A flu shot or steroid shot a recession shot so they're different types of fillers to most of the popular to lose in a market a semi permanent which means they actually last between. In my experience late nine months to two years and so they stay in your body needs so they don't just get absorbed overnight like you know a flu shot or or you know camera shot and does so care must be used to two two in start in all inject these Phyllis because you know it can cause a problem I had treat a patient with the pharmacy on dissipation has under I treat it with the wrong filler type that is just to It tracks to hydrophilic so it tracks water and so it causes you know just don't deformity is not terrible you know life threatening which I'll but it is terrible for the patient and not so I had to reverse it is not an emergency refers a which is different than a vascular compromise some when you have a bicycle compromise on any of the blood vessels block you got to act fast and I do have some concern if the person who's injecting don't have to experience or even the tools to reverse the problem the patient is in serious trouble and so the. There's only. In early ninety minutes to work with that and let's say if someone since that cart they don't have to hi you're on today's in your office. That could be a little difficult and so the patient can drive to little rock and then hoping the doctor a little rock may have to antidote and then even having to answer the they've never done one you have to read the instructions how to do it you know so in my office I have a crash kit and I already have the you know is pretty much a cheat sheet how do you makes this because you know we don't do that often fortunately but you you've got to have it in kind of like you know someone set over those you wanna have not can available is is emergency room. Thank you and and Mister Sherrod likes to tap for if she could come up at some point for the nursing board and paid I'd like I'd like that. We've had a registered nurse testify for the rules that I appreciate that thank you for being here in your testimony thank you for your Dan for your patience thank you. And we'll have a nursing board come up as soon as we have the testimony finish. Senator hammer thank you and thanks for being I'm over here too far left ma'am governor thank you thanks for being here specially on your own time duly noted appreciate that when you. You're using the term of I thank you for using the term in plant are you referring to the actual injection of are those words interchangeable is the substance being injected. Is not so much the man of the injection is the substance being placed that becomes an implant I mean it's not permanent semi permanent but it does culture to. Physical appearance and anatomy because it stays on the disc in full however duration it stays okay and if maybe you know the answer this question maybe you don't but when ever it is that you bill insurance companies for the implant or the procedure do you bill it is a build under code that implies that it is a surgical procedure or is it considered something else. Of the seat I'm not sure if is considered surgical there is a CPT code for injections of Chemo injection of neurotoxin I don't have that co with the there's also a a CPT code for Injection of a dermal filler and unfortunately these are considered cosmetic so insurance don't really pay for it so we don't even fall insurance for it okay such all this is basically paid for out of pocket the majority of the time yes and I think there is that's why there's such a. Hot pursuit fielding these treatments whether someone's qualify or not and and that's why I'm here you know because I I I really fear the complication rate would dramatically go up. Okay and I wanna say something but I'm just putting both arguments on table it could also be that that's the reason that they're such a defense in order to implement this rule is because there's also a vacuum away from other Oct from from other physicians and clinics as well it could be argued from both sides public health I'd be number one of a grant that so last which would be this if if the doctor feels a script. And it is given to somebody who's going to administer it other than the physician who wrote the script or the individual that wrote the script and something goes wrong. Who's held liable for the actions is that the writer of the is that the person who wrote the script or is it the person who actually did the procedure or if there's a court case who's going to get dragged into court. You have to ask the lawyers I II I really don't know but I a few. As a practical physician practicing physician I feel that if you're prescribing something Willie is your responsibility and I an unfortunate once again I'm not seeing that in the state you know and I'm not saying. Every clinic who does this don't have a supervising physician's but there definitely places that don't do not so the the supervising physician is not really supervising so okay and you've never read a script and give it to somebody else to. Never never part thank you thing Mr. One more question Representative Gonzalez thank you Mr chair I'd do appreciate your concern for patient safety in this and you mention the holodeck several times but that that's not a requirement in this rule that that these positions or whoever is administering that has that on board I do think that would be something that would that should be added yeah we talk about training we talk about you all the necessary things that that you should have and I don't disagree you know if you're gonna be doing the same as you and and there's potential complications maybe you should. I did absolutely I think. If someone is properly trained hopefully they will see the importance of it but you're right there is no requirement of it and the so that's the part that you said you're a general surgeon right okay was was botox and fillers part of your formal training or did not too hot not over twenty years ago. Photo some is the since that time has been used in other you know general surgery application but definitely you know the like list referred to really is involving and there are. Continuing new approval for approved fumble talk some use so let's say for example twenty maybe twenty years ago those only approve for between the brows I believe maybe three four years ago is extended his approval to treat you know the crow's feet and FOR had but in the past those will consider off label use of physician can prescribe treatment in locations that's not FDA approved but you know this call off label treatment with nurse practitioners cannot prescribed off label correct I'm not sure if you know you'll have to ask the nursing aboard Lee that is correct that they cannot prescribe off label so they would not be able to do some of those percent is being done. Well then the nursing board has an Avenue to go after those of their if that's not part of their nurse practice act in there another sorry Avenue to to go out for that so before you signed up with the company to order Uh botox and and the fillers and stuff that those companies require you to have training before you could ever order that. Not really the ages require licensed the DMB not guilty a but they require you a medical license number so they'll sell it to anybody with a medical license numbers yes Mister they may I send off for you but is not required. Okay so for example if is that someone who just came out of a. Dermatology training residency they've had the training so they're not going to necessary make them go through training again so I don't is there license they don't ask for for any type of proof of training that's correct that's why is important to have some sort of consensus that say will not just a physician can order this but up a tree a physician should be trained and and the level of training. You know date it could be. I think it could be up to the physician but you know it will be nice to have some sort of consensus but you know we if we're not trying to exclude all limit some people some scope of practice you know I things some level of training would be nice you know but no level training and not even close to the the location of. You know as having someone delegated to do this is just not acceptable. I don't think there's anybody in here that would disagree with you know some type of training requirements for for doing this so as a position you can delegate to nonlicensed individuals of certain procedures do you believe that you can delegate to them things that you are not trained in. I should not definitely not a and because as a physician if you're delegating your supervising them and how could you supervise if you don't have the knowledge right. So that was part of the test money opening up this whole discussion was that this was to go after the nonlicensed people who were injecting but they as somewhere down the line there were delegated. They were delegated that task my physician and in rule regulation thirty one under the medical practice act section to the this is procedures FOR delegating medical practice it says a physician shall not delegate a medical practice that is not within the forty of the physician or. But is beyond the physicians training expertise or normal course of practice so it seems to me like we already have that in the medical practice act and this would be a duplicate or work. Trying to regulate the the nurses on it so but also show like there is some. Issues with The prescription to so which is doesn't sound like that was in there so as you know these are prescribed products so let's see if a regular nurse on. A registered nurse may not have to license you know and I guess that's exact point that I'm getting at is they have to be delegated because it is a prescription product so that registered nurse couldn't prescribe that they couldn't get it on their own so it had to be delegated by my physician and it's already in law that a physician cannot delegate something that they're not trained in. Thank you. Thank you senator Irvin you're recognized. I just think the attorneys need to probably be the ones to specifically address your questions and I would appreciate if Mr acquire could come back up and and respond thank you. Okay thank you very much for your comment thank you for your time I think we have us Senator hammer and senator Irvin did you also want to hear from the nursing board. We have a Representative from nursing board come forward please. If you would please introduce yourselves and have we have a lease one question for you. See Ted for director of the board of nursing. David doesn't general counsel for the board of nursing thank you Senator hammer you're recognized. Yells name has been invoked in the conversation without having the opportunity to respond so let me just begin by asking is there anything you'd like to say in response to anything that's been said today where your name is been invoked. I don't think anything was said that was not true we've been working with the medical board for over five years of the problem for the nursing board originally came about because an LPN was working in the back of the a beauty salon doing botox with no supervision whatsoever that was a little over five years ago. She ended up surrendering her license because she was totally outside or scope of practice and administration of these medications are prescription drugs is been said over and over I appearance to have prescriptive authority and can prescribe the medications but our instant LPNs do not have prescriptive authority administering these drugs without oversight of the physician or in a PRN is outside the scope of practice and has been since the nurse practice act was written in two thousand and thirteen. So what is the yeah I've I've heard it stated today that you have a companion bill is identical to what's being presented today or what are the what are the differences because just put a point blank were you know some of the server kind of getting it from both sides as far as doctors for doctors against it nurses for nurses against it so do you have an actual companion bill that aligns a hundred percent with what they're presenting and. The does not a line one hundred percent we added the board approved last week adding a section on allowing our ins to provide these treatments botox and dharma fillers under a standing order protocol so just adding further guidance to for our in practice. And that's really the difference. Okay I'm on hold at this time Mister let somebody else. Thank you Representative Gonzalez. Thank you Mr chair the LPN the two that you mention it surrender license do you know she continued to practice without a license after. He surrendered issues still given direction by the position that she's working under two to do this and jackass it's never been reported that she has so I have no knowledge either way okay but it wouldn't necessarily be reported to you because she's now nonlicensed wrecked but she could potentially still be doing it correct without a license okay it is it do you believe that it's within the scope of practice of any nurse to perform surgery. It depends on how you define surgery because if you talk about surgery of just cutting the skin A. P. R. ends all the time remove miles they do signatures and they do other things that are basic to the the body. But it's not within their scope the surgery is not defined in their scope is as them then able to do that so we redefine this. As a surgical procedure and we're allowing our ends to do this now is is that not a scope of practice change. No. So we can change. We can allow them to do surgery without a scope change. It's is how it's defined the surgery now they can go in and do a thoracotomy or open heart surgery now absolutely but doing minor surgical procedures is always been within scope of practice. Okay. Representative Dotson you're recognized. Thank you Mr chair just going back to something you said at the very beginning you said an LPN had done this and then surrender their license several years ago yes So it seems like the problem to carry itself what with the need for this. The board of nursing and I can give you exact numbers received over sixty compliance on a static practice throughout the state there within a few against a PR ends with the investigation rule of reveal that they were trying qualified had a collaborating physician were totally within the scope of practice mode you already have more against our ends a few of them against LPNs and the complaint basically states have no oversight from a physician or a advanced practice registered nurse so according those camp complaints I mean how many of those words substantiated is as actual and there's disciplinary action taken. Said sixty of them what time was that there still some under investigation the complaint started in two thousand. Hello I am gonna guess here about two thousand nineteen maybe like two thousand eighteen Some of them are still under investigation so we've not done anything with them because we're still gathering data a large portion of a more substantiated and we issued a letter of warning and as it was previously stated it just said you violated something what it says is you violated your scope of practice by the ministry medications without a proper prescription and if you continue this practice you will be disappointed. Can you can you give us a list and a break down of all those and what the status of them are and how long does it take to to get a once a complaint is filed. You know is it is a you said some of them haven't been taking care of but they start in twenty eighteen twenty nineteen I mean we're getting close to the end of twenty twenty that's kind of a long time for someone to have a complaint hanging over their head what's what's the urgency factor that you take complaints and turn around and give people some some. Fine alla T. on their the outstanding thing that's out there hanging over their head well first we say some of the complaints of received one as recently as last week so of course nothing's been down there some of them did take I would say an excessive amount of time. Maybe a year but we got a whole lot of complaints at a time we sent over to the department health pharmacy service investigators we wanted to complete all of that massive group that we received at one time so that we treated them all equally and fairly depending on the facts of the case so we wanted to get all the facts together and decide where the violations were because you don't wanna be arbitrary capricious and start going off on these different directions and treat you very harshly entry to very easily so the we want to be consistent in the way we were treating individual so the first ones did take an excessive amount of time and I won't tell you anything different on that now they're moving much quicker because we have a standard to county judge this is the way we're going to handle these cases. and we probably have and I'm I'm guessing maybe ten cases outstanding if that many but again one came last week one came last month so it does take a little bit of time so so you said you had a large group of them all the same time where they from the same source or. Competing a competitor that was complaining on other competitors and they're allowed to complain anonymously a group of them I would say yes as somebody mentioned from competing position based on the way it was worded I would say there were all from the same individual but then we got another group that appeared. And this is my opinion there it was anonymous came from a disgruntled nurse that would put against some of her co workers and some of them you can tell because they were very different than the other one so it's hard to tell but they were all anonymous. Okay so at I guess I'm just trying to get a little bit of a handle here on the set a large group of them lot of them from the same source but you had sixty of them in the last year year and a half for two years When you say a large group is that thirty of them is that forty of them it I mean I I've never looked at it to say these are from this individual I would say closer to maybe twin AT okay but I've never divided amount to figure out trying to about a third of them started in one area probably northwest Arkansas even not from the same individual that all a lot from northwest Arkansas okay. Thank you. Senator Irvin you're recognized thank you thank you and so I appreciate the testimony that you ACT gave and and one of the things that was said there was a statement I believe that that this previous legislation allowed a parents to use any physician in the state or R. their requirements. and so I'm not sure for really arguing you know what we're arguing here is that collaborative agreement is that scope of practice is that you know what is it but are there requirements. There are requirements is that correct from one understanding that you have to have there are some requirements in that legislation. That allows the let a parents to use any physician and what are those requirements there really are numb with this law that was passed it really helped R. A. purines then rule areas basically the roof the main requirement is a physician with an active license under the medical board right now we do prefer them to a line but I have not rejected collaborative practice agreements that don't align right and I understand that the medical society was supportive and helped draft that legislation is that correct that's my understanding thank you. Senator hammer you're recognized thank you of all those complaints that you receive do you follow up to see if the complaints had adverse affects on the patient themself. With none of them was patient specific a large member for well almost all of said the nurses practicing without a mid level provider oversight and we have one patient compliant were harmless to a patient and there was billing fraud in that want to use the nurse had to come complaint to get in the way of I only have one with harm to a patient. Show of all the complaint she received only one has harm to the patient which would be a reasonable conclusion that the complaints might actually have something to do outside of the patient physical welfare he could be Tyr four could be of billing it could be money it could be anything else that would motivate somebody to call in an anonymous complaint I agree. So in your opinion and maybe the attorney wants to answer this we've heard scope of practice though around the room this morning is this a scope of practice issue in y'all's opinion. Well yes I think I think it is. Because well it's not a scope of practice regulations go practice what it is is just giving more definition to what the rules already say it's far from the nursing board. From what the rules that we promulgated. An. These. Certain oriens LPNs were outside of the scope of practice. Okay so that is the issue that that that has caused us to see the need to. Promulgate a rule that addresses it okay so is it fair statement not put words in my house is that a fair statement say what precipitated this whole conversation is because it touched scope of practice issue. I would say in yes if someone was acting outside the scope of practice. Okay thank you. Representative gray you're recognized. Thank you Mr chair have thank you almost lost my train of thought more up the question I had and. I guess I I'm still trying to figure out why we need this if you can already because you talked about the opinion that you already discipline so that you're able to discipline you can discipline oriens. So the people that we would not be able to do anything with are those that are licensed and this does not fix that. You're absolutely right we we can't discipline these nurses already based on what the nurse practice act rules currently in place we were trying to add some clarification so that it's very clear that you're outside your scope because a lot of the nurses they don't realize and I and I've of ascomycete okay this is a prescription medication can you give the Santa Boddicker this blood pressure medicine without a prescription well no well this is any different but I don't understand that and so we're just trying to clarify to help them understand where they need to stay okay that's I guess I just assumed because it is a prescription that it would be treated like any other prescription and we we don't do we delineated statute or in rags somewhere that says all of its beside schedule to your narcotics do we say will. If it's this type of prescription you can or can't do this this is the only one so just because they don't understand it doesn't mean that we don't already have the ground work in place it's possibly just an education issue if it's a prescription it's a prescription correct okay thank you. Representative Vaught you're recognized thank you Mr chair and so I heard the medical society say that they had been working on this issue for about five years would you concur with that mean medical border medical board to sire yes Sir we've been working jointly together about five years okay and so the problem I guess is what you would consider growing. Yes okay so my question is and that five years I've I've been here for that long myself and we've had three regular sessions during that time why are we now when we're five months away from a regular session when this could go through the proper channels why are we all of a sudden now we're at the deadline we've got to do this I threw a rule change instead of it going through a public health and it being an at the X. legislatively. I think it's just taken is that long to come together on joint rules it was not an easy process and somebody said we usually don't agree on anything so we work very closely trying to get a joint agreement of how it should look we did a lot of research both boards did of what is everybody else in the nation doing which that make it good or bad but we we were trying to get our ground working is just taking that long to get thanks three and we we just both boards really believe rule was the correct way to go at the time. At so I have one other question I'm not sure if I heard senator Irvin route or not that I Kerry this and I just want it to be known that the medical board did not bring me that legislation so it if medical society did not bring me that piece of legislation I mean they might have not fought it in committee Mister chair but they did not bring that to me so thank you. Senator when you're recognized. I'm not gonna comment on any of that amend that they can get to the table but I would just ask quickly is education and how things have changed and this is changed rapidly in this space. And I think. With this rule does based on your testimony you have existing rules you have existing legislation and your operating within that existing legislation to try to clarify. And bring some level of clarity is that correct that what you're doing yes you're trying to leave bring a level of clarity. Write in as an example I think during the public comment period there Senate some people. Stated that before they set their their client except. Or whatever they call on they consulted with a local attorney in the local attorney gaming devices in that attorney. We disagree with the advice that that attorney gave them as far as what's within the scope of practice and and I don't think the attorney did that on purpose and so it does need some clarification. So I see this as a liability issue to which is why just what you said eight state it this is a liability issue too I mean this is about patient protection about patient safety but it's also a liability issue so we need clarification inside of our rules in order to protect not only the patience but also those who are operating in this space. And and if they need that level of clarity that's what you're trying to bring and in reference to the way that this is written the language is consistent with previous legislation and and that is that is what I'm stating here is that I see consistency in the language that is used in this proposal for the medical board in previous legislation. And I think and again I appreciate the testimony. We we can have a discussion as to whether you know this I mean yes if if I am somebody Hugh is not a registered nurse. Then clearly this the changes my scope of practice because I'm just making up my own scope of practice. So I mean at some point we have to understand that there is a law we're trying to abide by the law. So the though it you can you can mix all of this stuff up but it's real clear in the law and and clarity in the law is always a good thing and not necessarily a bad thing in my opinion and so I do appreciate the efforts that you automate I do appreciate the testimony and I do appreciate the collaboration and I will look forward to passing your role when it comes for thank you. Thank you for your comment thank you committee. Committee have we've heard a lot of testimony today I've had several ask about a motion to refer this to public health and Senator Hendren would you like to make that motion. How do I hold hold Senator hold on the gut Senator hammer one last question Senator did you. Okay. Hendren at thank you Mr chairman again I've been on rules and I'm not think I remember is getting so much to what sounds like a scope of practice discussion and I think we all know that we do those in public health in their special rules for so I move that we send this to public health for consideration. Yes second with Senator hammer. To have been a discussion. Without objection we will refer this to public health. Objection thank you thank you very much. Okay. We will move on to number seven and that's it I mean we got here. We're gonna try to go one through this if you have any questions about that talked Representative love. what number seven apartment even services. Barker quick down there. Go right ahead in addition self and go you may begin thank you Mr chairman mark white with DHS with three rules for you today this first one of this is for a long term care ombudsman program hi this program that's been in place for many years they provide advocates for individuals who are residing in a nursing home or assisted living facility help advocate for their interest in the system for any complaints or issues they may have the feds change the rules around the several years ago and as a result we had to redo our rules and because there's so many changes on the federal side we decided be better simply re write our our policies from scratch that's what you have in front of you not aware of any controversy or concerns out there I think we've worked with healthcare association and with others around the state to get the same shape and that'll be happy entry questions. A. Representative Gonzalez. Thank you Mr chair how have those ombudsman men of advocating for the patients through this covered crisis when I haven't been able to see the families and haven't had the access to things that they normally have it's it has been tough because of limitations there I know they have tried to reach out families know in the came to their person they can still call them thank talk with the family members not even they can see the resident thanks to me with his family members so they tried to find as many ways around as possible make sure they're staying in touch their. Thank you. Had more questions on that. Senator hammer thank you how long you'll be working on this mark. It's been probably for last year and a half two years as bill involved a lot of back and forth with the fence we wanna explain that what they were proof okay and art did I understand you right that the ombudsman does or does not have access to inside the nursing home during the covert crisis right now they it depends on if the if visitation is let the nursing home if visitation is lot families another's the ombudsman can get access otherwise they do not have a physical axis okay and that I'm just going to express my concern with that because the obligee and are considered ombudsman to meet places critical role as anybody else and I respect the nursing homes in the job that they're trying to keep patients safe all about that however you've got employees that are coming in an outgoing Walmart or whatever they're going during that time and will allow them to have free access in and all those nursing homes but we're depriving the ombudsman from that personal presence and and I'm not sure that's a good. A policy to have and I I think there needs to be a discussion about that because if family members are not allowed in in the ombudsman's are not allowed in I don't think that's I don't think that's good for the patient to not be able to physically lay that set of eyes on him so like to have that conversation with you but then the other question is does this apply to assisted living facilities also ours is just nursing homes or is it both it's both okay alright so I'm just sending the flag of the poll I think that needs to be addressed is that a DHS or is that a department of health that the ombudsman is not allowed in I believe combination and we we certainly we've that's what we've been looking at as this is going on and we'll we'll continue this discussion happy to talk talk we talk about it and re evaluate is needed thank you thing Mr. I'd like to be a part of that discussion to place yes members I see no further questions so far no further questions this rule was reviewed and approved number eight RQ one introduce yourself and go ahead again yes Sir more quality it's just second rule this is the eligibility manual for transitional employment assistance or T. we're distance clean up here it shouldn't be any substantive changes in here just trying to make this manual of an easier read for our staff and FOR clients have to answer questions. Members I don't see any questions. So with no questions as rules reviewed and approved. Are you number nine looks like mark go ahead yes Sir number none I can mark what DHS this is for Medicaid you may remember the several years ago we institute a program called Abbas episodes of care to help introduce best practices in medical treatment and also to hopefully saves money we thought that was a good program and cheat a lot of progress for the system we think it's reach the end of its useful life at this point and so we're planning to sunset that program and that's what this rule document my comment would be it rich to use for those years ago but glad of moving members any comments or questions seeing none this rule for viewed improved thank you member thank you very much Ron item ten department of labor. Members I appreciate all hang around for the thank you. If you would please introduce yourselves you may begin. Thank you Mr chair my name is Diana Piasecki and I am the director of the department of labor and licensing Arkansas appraiser licensing and certification board Marcus divine deputy associate counsel that that the labor priced by. Of the Arkansas appraiser licensing and certification board is proposing revisions to our current rules the board the secretary of the department of labor licensing and the governor's office of all approved are changes public notice was published in the Arkansas Democrat Gazette and on the board's website as a result of the publish notice the board received one written comment to correct the spelling of energy from inter G. E. this misspelling is considered non substantive and has been fixed the board held a public hearing on August the tenth there were no member's at the public in attendance at the hearing a quick review of the repose of the probe some of the proposed changes is we corrected that we change the word regulation and replace it with rules were needed we added corrected and remove definitions we added the registered apprentice quite appraiser classification we made corrections to the education approval process and requirements and what these revisions did were put all of the education information in the same section we remove the terminology moral turpitude for clarification the board separated reciprocity temporary practice permits and transferring an appraiser credential to the state of Arkansas we added a section for military veterans and we added a section to detail criminal background checks and pre licensure criminal background checks and with that I'm happy to answer any questions. Representative Dotson you're recognized thank you Mr chair my question is in regards to one the comments that you received from our bureau staff Numbers three I think it is on the list concerning pre licensure criminal background checks you had responded saying that the board considers a quote reasonable time to be twenty five to forty days do you have a more specific time than twenty five to forty day range and can you actually put that into the rule specifically allow that length of times because it depends on when the board meets again it would need to be at the next board meeting and we only meet once every other month okay so I I allowed it may be a shorter than twenty five days if the board meeting as soon or maybe longer if it we what should be longer than forty five days but that's what issue these rules they've they've actually put at the next board meeting okay would that be an acceptable addition to this that that you could add to this rule I'm happy to make that change okay I would ask that we do that to approve this. Appreciate Mr chair. Senator hammer you're recognized thank you and working in another area that involves the phrase also reasonable time as defined by the Attorney General in an opinion on the does the board have the right to continue to indefinitely table issue so as not to have to take the issue up as it currently is in with this address and preclude that from happening. Okay you're going to have to I'm not sure I understand your question help me what it what specific. Is it maaf five days for expedited credentialing I guess my question is the board the board has to take this up and consider of it consider it within a reasonable time frame in your twenty five to forty five days is based on the time frame to which the committee would meet and so you synchronized it to one the board would meet next is that correct yes Sir and I would make a decision that day. How do you know they make a decision that day and not just table it until the next meeting continue to could table an issue and definitely Sir robin with that board eight years and I've always settle things on the day that that the board meeting we we tried not to type of things ever and I've never seen that kind of decision be be typed okay and that's commendable that you are yes that yes be yes and your no be no commending you on that I'm just really kind of seeking insight as to why you know why you put that time frame in there anyway at that the way I understood the question and I knew that it would have to be at the very next board meeting that was the only reason I allow that much time okay alright thank you thank Mr. Or at the next board meeting. Okay member for rent see this of Representative Dotson if it's okay with you as approved pending. Pending a response to Representative Dotson are you okay with that Representative are you all are at the yes Sir will sit as reviewed approved if you'll get with him and clarify that okay thank you Sir. Any I will need a revised copy of that before Friday so we can move forward if you would please okay. Okay with all right. I'm Sir are a senator Irvin had a question go head just some background please sorry what it might be question to bureau but does that revision for choir it to go back to the process is just a minor revision it's a process question. That question turns on house substantive because the changes to the nature of the rule that's a decision that's historically been left to be agency on their interpretation of whether that would required to go back out. we we think this process requires that it would be useless if you all could make changes to a substantive issues before they were rendered promulgated and so to us this is part of the process and so if you know yes No I don't disagree with that what I'm asking is the change that was requested is that going to are we able then to review that on Friday or does that require the in the rule to go back through to the public comment process there's no reason you but I would say not I would think that what you're doing is appropriate and and proper and as we go forward prior to promulgation your change the changes that would that have been mentioned would be on eating publishes so just be a determination of whether OP substantive or not that correct yeah and to the extent your question moment of senator Irvin understood the approval to be contingent on the addition of the language that represented Dotson had requested I think she's asking do you have to go back all the way through the process all over okay and I don't I would leave that to the agency's determination we would think not because that's why you have this process is that allow every step to have some changes in when you have public comment for instance if someone makes a comment you don't have to go back and re notice the whole thing just keep moving to the steps okay I was just thank you fifty. Representative Dotson thank you Mr chair if I can just add one bit of clarification this this is a semi requested several agencies have have accommodated over the last several months as removing through these these real processes and and I'm actually gonna ask question on for more from before we finish today's agenda so I I I agree with you and I think that's a good determination and every other agencies made to the today yes that that helps out. Okay this is reviewed approved pending came back Representative Dotson before Friday okay thank you if if I could not miss gesture on to the question that was raised about tabling I'm not aware of any limitation that a board has to not table something and so board can decide to table things as they see fit as a matter of I know he's talking now but I want to make that clarification. Okay okay. I will move on to. Item eleven. Department of labor licensing division of occupational and professional licensing boards. You within introduce yourself. I thank if I'm correct you'd talk with senator Ballenger are you who's presenting others from okay go ahead. I work for the department I was gonna stay seated but I think they're all come. Marks the month in the department of labor. Okay you may go ahead present. And in addition cell first place Kerr Clark on the chairman of the bill bond licensing board. I'm Daniel Faulkner assistant Attorney General as many of you all know we represent in our agencies division boards and commissions so I'm kind of pinch hitting for bread knife who do the heavy lifting on this so I'm here to run to the summary of changes and was Mister you have a question about senator Ballenger thank you talk with your all in our as one to confirm you have met with him and discuss some of those issues that is correct and I'll cover that real quick summary you may begin thank you Mr chair members again Daniel Faulkner with the AG's office the first part of this containing your summary it's a lot of the bills from between nineteen session you're familiar with cleaning up regulation verses rule from ACT three fifteen there's a new section added to address returning military spouses and veterans and active twenty there's a new section dealing with reciprocity in temporary permitting from ACT four twenty six and ten eleven there's two new sections split up for a criminal but pre criminal background checks and in that waiver process from ACT nine ninety again you're familiar with all those changes and to the chairs question there was a sunset review under ACT seven eighty one of seventeen were some issues were flagged a by senator Ballenger and the board is made several changes as a direct result of those comments section eleven dealing with them secured bail bonds is deleted there's no statutory authority for that section because the statute actually was repealed back in twenty eleven section sixteen see there is a requirement the bondsman be physically present upon release a defendant that's been deleted no statutory authority fifteen D. that can have a permanent industry wide removal for being revoke you can even work in the business basically any capacity that's been removed for no statutory authority section twenty four several sections dealing with financial reporting and some reports asset reporting was removed same thing. No statutory authority and then finally and rule thirty four rule twenty seven dealing with the hearing procedure and some practices upon revocation that's been tweak a little bit to comport with due process and part of it's been removed because of no statutory authority so yes senator Ballenger's concerns to my understanding are addressed in all these changes the to my knowledge there is no negative public comment at this point I would be happy to take questions certainly the chairman is here as well. Thank you and members we do have a public comment on this one too but go ahead if you have any questions Representative Dotson your you are recognized thank you Mr chair if you were listen in the previous one I know you are Marcus the Again. The thirty days you responded on the pre licensure thing that the board would would here within thirty days can you put that into riding in the rule that if the board will respond to. With the decision in writing to a completed petition within thirty days of the receipt of all documentation I think we've already done that represented Dotson if you look at section twenty two. Section so last night as I was going through this let me pull back up sorry I don't have that one on. The. This. Thirty. You know what page of the rule this is on. Section twenty two. I don't have a number paid to represent of I'm sorry. With specified thirty days receipt of all documentation. You did sorry I missed that one so thank you. Russian and we can thank Mister Nye I've. Representative were you finished. And Mr Clark are you Mr Clark yes Sir okay I'm sorry I had and had you down here speaking you've spoken I take it of members I see no further questions so with no further questions this rule is reviewed and approved thank you thank you Mr chair thank you. Move on to item twelve. Department of labor. Mark is done so she counsel for the department of labor licensing. Some of you introduce yourselves remember again thanks Sir Greg Crowe the ministry director in most places but my titles administrator contractors licensing board department of labor licensing. Michael Langley attorney for the part four of the contractors board. Maybe yeah. Thank you. Our rules are the ones that would discuss mostly a whole lot today the criminal background information pre check and the regular check on writer application bird by nine ninety and also the reciprocity and What I'm looking for sorry other reciprocity issue and Taking a allow a license for someone to come of another state under acts four twenty six and ten eleven. the. A pretty straightforward all you have to take any questions about any home here we're dealing with item a only correct. A list I apologize Mister item a was FOR the contractors board out that's I'm sorry yes I apologize thank you the last record background check apologize for getting I'm trying to work out of town out of may yes Sir okay members to it Representative Dotson here question you're recognized thank you Mr chair if you've been listening to my questions cancer and I don't believe this one has been updated I just put up no it has not can you define that reasonable time. I'll be my only issue with an appropriate hypothetical but I'm I hop a rule follower I like to do everything. Precisely the same thirty days we do meet monthly as a rule I have been there twenty years and we've never met less than monthly but is it possible we would meet in a month and like and we met early in December because a Christmas and then met late in January I guess I'm a hopper rule or so scared me to death to say thirty days can you change it to where it says the next available born meeting next available board meeting yes or we can we can do that thank you The same conditions will see this as reviewed and approved providing you provide that information prior to our meeting Friday yes Sir. Okay with no further questions this rule is reviewed and approved pending that and we're on item be item B. as apologize for getting ahead of myself is on as for the ACT four twenty six and ten eleven of the house for a ninety day temporary license if you've got a license in another state also allows for an on a temporary license if you can show us a proper experience to the that's the if you come a stated that have a license. In center hammer you have a question I do Mr chair thank you I think this is one of got some calls about now I remember the legislation go through to clarify a couple things for me so somebody moves in from out of state and they use an elector should for example so they move in from out of state they got electrical license in another state but they haven't been licensed here they're granted a ninety day temporary license is that correct. First what that would like Christians you got two layers so elect first they would have to have hello but a license from the electrical board and I can see that the the Democrats that but if they have that yes the in the give his requirement for electrical license to have the logical license will to go board before we can give you a contractor's license with a logical classification if you want to talk about a building license then that was yes you got a building license from Virginia and you you would and show us that when you apply we will give you I'm not a temporary license all right and that was intended that it people move in the state they can go to quit work quicker yes I got ninety day license at the end of the ninety days refresh my memory let me use electricity specifically at the end of ninety days of. If they're not permitted it goes away and they can't continue is that correct that is correct so it's not tended to take the guy that's going through the electrical class you know paid the three to five years sweat equity dues and it would not replace I mean they would still have to go through the same course to be a master like Christian journey men and all that stuff right. Very true and as you can imagine the point is just to give us time enough to validate their licensure in the jurisdiction where they come from when this over a catch alcohol okay thank you. Thank you for have a friendly conversation right. Folks see no further questions of this rule will stand reviewed and approved thank you. Item thirteen department of labor we are the same group the answer would go a and then be cells are. Total toxic when order this time I apologize a in the this is on the residential committee which we have to separate boards a commercial board and residential committee to same to rules and again in the pre licensure we would absolutely be happy to make that correction and we will get that to you this afternoon or early in the morning to take care of that but the rest of it is almost identical word for word from the one you just reviewed. Members fee no question so with no further questions disservice reviewed and approved. Item be autumn B. again as the temporary license people coming in and also again if you've got a license another state you don't that that's this call the same type of life and you're not going to show me experience get a licensee that's one thing that that we do so if you've got a building license from Virginia I will give you a building license here. Okay an automated to clarify was pending Representative Dotson as I think you said that my Mr okay item be any question of members and saying no questions this item is reviewed and approved and number fourteen thanks thank you all department of labor. Marcus to mind so see counsel department labor. Good afternoon Andrea offered executive director real estate commission Arkansas department of labor licensing. Go ahead you may begin. Thank you. We are submitting for review and approval rules four point five and four point six in accordance with ACT eight twenty of two thousand nineteen in acts nine ninety of two thousand nineteen of course ACT eight twenty required occupational licensing agencies to provide for automatic licensure for active duty service members returning military veterans and their spouses to engage in their chosen professions the purpose of this rule is to grant automatic licensure for real estate broker or salesperson for active duty servicemembers returning military veterans and their spouses. Acts nine ninety of two thousand nineteen required licensing agencies to promulgate rules for applicants for licensure who have criminal background records and the purpose of this new rule is to allow individuals with criminal background records to file a petition for a pre licensure determination of whether the individual's criminal record will disqualify the individual from licensure as a real estate broker or salesperson and whether a waiver may be obtained. It's come to our attention that there is some concern over rule four point five for ACT eight twenty. In that the rule does not include the definition of a automatic licensure as set forth in ACT eight twenty in light of that we respectfully request approval of the rules contingent on adding the definition of automatic licensure verbatim from ACT eight twenty to rule four point five directly following the definition of returning military veterans in the first sentence of rule four point five and in accordance with Representative toxins request we would also agree to add to thirty days and the reasonable time period section of rule four point six for acts nine ninety. Representative Dotson I have nothing further okay so this will members any further questions if none this will be reviewed and approved pending the changes by Friday. Thank you Mr chair thank you. And on the number fifteen public service commission. If you would introduce yourself you may begin. Sure button on there. My name is Donna great I'm when the executive director of the public service commission. What we have before you today they are a few refinements to the Arkansas gas pipeline code this is a commission rules that are addressed safety for pipeline operators in the state intrastate. The federal the Arkansas law requires that the state pop one safety code be consistent with the federal code so the few refinements that are reflected before you are only to reflect this similar changes at the federal level so that's in compliance with the law we also are certified to receive federal funding reimbursed on a reimbursement basis and part of our agreement to receive that finding requires that we mere or the federal standard and that's the basis for these changes. Thank you I see no questions with there are no questions this rule stand reviewed and approved thank you very much thank you. Members were moving on the item ET in our final item on the agenda will include updates by agencies who have not completed their rulemaking in accordance with ACT five seventeen of twenty nineteen with respect to the first agency on the list I'm the one the department of agriculture the Arkansas bureau of standards you have a letter in front of you and if there's no objection will we are we will review and filed that letter. The objections of that will stand filed. And with that we'll move on to item number to the apartment commerce. No appreciate you hanging around hope you enjoyed the discussion and if you will introduce yourself and proceed Mister chairman I'm gray Turner's to see counsel with the Arkansas insurance department here for rule one twelve. We have completed our hearing process and we have the public comment period has ended so we will be submitting this rule for consideration before this committee at the next available me okay members any questions. This review and FOR. Okay thank you. This review thank you. And department of health. Davis won a lot today so. If you would introduce yourself you may percent. Thank you members of the committee lar sue them general counsel for the department of health and I'm here to report on AT ACT to sixteen this is the human breast milk standards rules and we have been working on this for about a year we have gone through the promulgation process twice and so this was one of those rules where we determined that the public comments did have an effect a material effect on the rule so we went back through the public comment period twice before board of health twice the public comment period ended on September third and we are working through our responses to the most recent public comments hope to get before public health either on the September thirtieth date were in the November and meeting dates for public health review first and then we'll be before your at great after that great sound like a moving forward if there are no questions this is reviewed thank you very much our final item is a highway commission. In addition softened again A bill Rogers with the Arkansas department of transportation FOR the Arkansas highway commission as was the case last time we have promulgated rules gone to the publication process public comment period has expired we received a few comments and the commission and the administration working on responses trying to determine whether we will make response make changes to the rules and if those changes are made how that will affect promulgation process. Hi fi no comment. This review thank you very much. A member thank you so much for hanging around for all this we are adjourned.