M I N U T E Smedia.southernnevadahealthdistrict.org/download/boh10/...Staff: Scott Weiss; Angus MacEachern; John Middaugh; Glenn Savage; Jennifer Sizemore; Bonnie Sorenson; Stephanie

M I N U T E S

Southern Nevada District Board of Health Meeting 625 Shadow Lane

Las Vegas, Nevada 89106 Clemens Room

Thursday, September 23, 2010 - 8:30 A.M.

Chair Strickland called the meeting of the Southern Nevada District Board of Health to order at 8:35 a.m. and led the Pledge of Allegiance. Stephen Minagil, Esq., Legal Counsel confirmed the meeting had been noticed in accordance with Nevada’s Open Meeting Law. Chair Strickland noted a quorum of was present at the start of the meeting with Members Anthony, Christensen, Eliason, Fairchild, Giunchigliani, Jones, Menzel, Onyema, Tarkanian and Vigilante seated. Chair Strickland mentioned that the meeting is being webcast to staff and asked both Board members and attendees to turn off all cell phones and electronic devices as they interfere with the sound system, which in turn affects Mrs. Clark’s ability to transcribe the meeting, and can interfere with webcasting. Board Members Present:

Linda Strickland Chair, Councilmember, Boulder City Tim Jones Vice Chair, At-Large Member, Regulated Business/Industry Donna Fairchild Secretary, Councilmember, Mesquite Stavros Anthony Councilman, Las Vegas Jim Christensen, MD At-Large Member, Physician Robert Eliason Councilman, North Las Vegas Chris Giunchigliani Chair, Commissioner, Clark County Nancy Menzel, RN At-Large Member, Registered Nurse John Onyema, MD At-Large Member, Physician Lois Tarkanian Councilwoman, Las Vegas Jimmy Vigilante At-Large Member, Environmental Specialist

Absent:

Kathleen Boutin Councilwoman, Henderson Lawrence Weekly Commissioner, Clark County

Executive Secretary: Lawrence Sands, DO, MPH Legal Counsel: Stephen R. Minagil, Esq.

Other SNHD Board of Health Members/Alternates Present:

Kam Brian Alternate At-Large Member, Regulated Business/Industry Michael Collins, RN Alternate At-Large Member, Registered Nurse

Other SNHD Board of Health Members/Alternates Not Present: Travis Chandler Councilmember, Boulder City Alternate Tom Collins Commissioner, Clark County Alternate Susan Crowley Alternate At-Large Member, Environmental Specialist Karl Gustaveson Councilman, Mesquite Alternate Joseph Hardy, MD Alternate At-Large Member, Physician Debra March Councilwoman, Henderson Alternate Frank Nemec, MD Alternate At-Large Member, Physician Steven Ross Councilman, Las Vegas Alternate Anita Wood Councilwoman, North Las Vegas Alternate

Staff: Scott Weiss; Angus MacEachern; John Middaugh; Glenn Savage; Jennifer Sizemore; Bonnie Sorenson; Stephanie Bethel; Noreen Clark; Cara Evangelista; Kay Godby; Steve Goode; Mary Ellen Harrell; Forrest Hasselbauer; Ann Markle, Robert Newton; Veronica Morata-Nichols; Patricia O’Rourke-Langston; Gwen Osburn; Mars Patricio; Jane Shunney; Vickie Swanson; Leo Vega; Deborah Williams; Valery Klaric Shelli Clark, recording secretary ATTENDANCE: NAME REPRESENTING Jamey Bailey SEIU 1107 Lynette Carpenter NSBMT Jeff Gerber PGAL Scott Hansen Boulder City L. Earl Hawley NCCI (signed in, but was not in attendance) Kathleen Peterson Self, Instructor of Environmental Law and Regulations Laurie E. Sanders Alpha ES Vinny Spotleson Sierra Club Gail Yedinak UMC OATH OF OFFICE:

Southern Nevada District Board of Health Members, Alternates and Officers Chair Strickland asked Shelli Clark to administer the Oath of Office to those newly appointed elected and at-large members present at the meeting. Shelli Clark, recording secretary and Notary Public, administered the Oath of Office to Kam Brian, Regulated Business/Industry at-large member alternate.

Board of Health Minutes Page 3 of 24 September 23, 2010

I. CONSENT AGENDA

These are matters considered to be routine by the Southern Nevada District Board of Health and may be enacted by one motion. Any item, however, may be discussed separately per Board Member request before action. Any exceptions to the Consent Agenda must be stated prior to approval. 1. Approve Minutes / Board of Health Meeting

: 8/26/2010

2. Approve Payroll / Overtime for Periods

: 8/07/10 – 8/20/10 & 8/21/10 – 9/03/10

3. Approve Voluntary Furlough Program Reports for Periods

: 8/07/10 – 8/20/10 & 8/21/10 – 9/03/10

4. Approve Accounts Payable Registers

: #1243: 8/06/10 – 8/19/10 & #1245: 8/20/10 – 9/02/10

5. Petition #20-10

: Approval of Amendment #1 to Interlocal Contract with Nevada Division of Environmental Protection (NDEP) for Local Underground Storage Tank Program

6. Petition #24-10

: Approval of Interlocal Contract with Clark County to Providing Funding to Hire Personnel, Conduct Planning, Training and Exercise and Purchase Equipment Relative to the FY10 – Urban Area Security (UASI) Isolation and Quarantine Project

7. Petition #25-10

: Approval of Interlocal Contract with Clark County to Provide Funding to Hire Personnel, Conduct Planning, Training and Exercise and Purchase Equipment Relative to the FY10 – Urban Area Security Initiative (UASI) Epidemiological Surveillance and Investigation Project

8. Petition #26-10

: Approval of Interlocal Contract with Clark County to Provide Funding to Conduct Planning Relative to State Homeland Security Program (SHSP) Epidemiological Surveillance and Investigation Project

Chair Strickland asked if there were any discussion on the items brought forward on the Consent Agenda. Member Giunchigliani noted a typographical error on page 36 of the Minutes and requested that Member Tarkanian’s comments be corrected to read “recused” versus “reclused” as presented. Seeing no further discussion, Chair Strickland called for a motion to approve the Consent Agenda.

A motion was made by Member Giunchigliani to approve the Consent Agenda as presented with the requested corrections to the Minutes; seconded by Member Fairchild and was unanimously approved.

II. PUBLIC HEARING / ACTION 1. Memorandum #15-10: Consider/Approve Application for Nevada Energy to Modify a Class III

Landfill for Reid Gardner Station, Located at 501 Wally Kay Way, Moapa, NV 89025 (APNs 042-07-000-001, 042-07-000-002, and 042-07-000-004) Staff requests that this item be heard at the October 28, 2010 Board of Health meeting in order to be in compliance with notice requirements


Chair Strickland declared the public hearing open. She noted that the Board must approve the continuance of this particular item. Dr. Sands noted for the record that this is a Class III landfill, not a Class II as stated. Chair Strickland asked if anyone from the public wished to testify on this item. Vinny Spotleson, representing the Sierra Club addressed the Board. He thanked the Board for continuing the hearing on this item and encouraged all Board members to attend the October 4, 2010 public hearing which will be held in Moapa. Chair Strickland asked if anyone else wished to testify on this item. Seeing no one, she closed the public hearing and called for a motion.

A motion was made by Member Giunchigliani to accept staff’s recommendation and continue the Public Hearing to the October 28, 2010 Board of Health meeting; seconded by Member Fairchild and carried unanimously.

2. Variance Request to Operate a Public Bathing Place not in Compliance with the Nevada

Administrative Code (NAC) 441.130; 441.134 and 444.152, Located at Project CityCenter Land, LLC, 3722 and 3726 Las Vegas Blvd. South, Las Vegas, NV 89158 (APNs: 162-20-715-000 and 162-20-714-000) for Health Permits 29839-/HP-01 and 27839-3ZP-01. Petitioner: Bruce Aguilera, Vice President and General Counsel, Project CityCenter Land, LLC The petitioner requests that this item be heard at the October 28, 2010 Board of Health meeting Chair Strickland declared the public hearing open. She noted that the Board must approve the continuance of this particular item. Stephen Minagil, board legal counsel, confirmed this is the best practice in the event members of the public are present today to offer testimony on this particular item and are unable to attend the next meeting. Chair Strickland asked if anyone from the public wished to testify on this item. Seeing no one, she closed the public hearing and called for a motion.

A motion was made by Member Fairchild to continue the Public Hearing to the October 28, 2010 Board of Health meeting; seconded by Member Eliason and carried unanimously.

III. REPORT / DISCUSSION / ACTION 1. Discuss Procedure(s) for Requesting Items to be Placed on the Board of Health Meeting

Agenda (requested by Chair Strickland)

Chair Strickland said after she became Chair, she was asked about the procedure for putting items on the agenda and she learned there is no defined procedure other than having the item presented at least eight (8) business days prior to the meeting. She said there is no existing policy. She feels it is best to know the rules of engagement and offered a suggestion of defining a written policy for the Board members to review and bring it to the Board for consideration and approval. She noted that in discussion with staff submitting items eight (8) business days prior to the meeting is sometimes problematic with a short timeframe, therefore she proposed a deadline of nine (9) business days. Member Christensen suggested an even ten (10) days.


Chair Strickland asked for input on how requests for agenda items should be submitted. She expressed her opinion that it is best to have requests in writing in order to track the history of the request, including if an item does not appear on the agenda, as well as follow through. Member Menzel asked if a request could come in email form. Chair Strickland said written form could be considered an email, a letter or even a form. She said she is not in favor of form over substance and when roadblocks occur the flow of communication is affected. Member Giunchigliani said a form is not necessary and that an email should suffice, including providing backup information and assistance from staff if required. Procedurally it was suggested that requests for item go through both the Chair and Dr. Sands. Member Fairchild suggested having two co-sponsors of any Board member initiated agenda item as the Board is so large – this is the process followed in Mesquite. Member Eliason said this is also how requests are done in North Las Vegas. He said this removes any political issues from the request. Member Giunchigliani expressed concern about serial conversations between Board members which could lead to a motion and a second, and in turn violate Open Meeting Law. A quorum of the Board of Health is seven members. Chair Strickland asked if the email communication needs to reflect the co-sponsor of the item, or should the co-sponsor follow with a second request. Member Eliason said the co-sponsor could be included as a CC on the email, and the body of the email could include the co-sponsor. Member Giunchigliani expressed her lack of support for a co-sponsor – the issue is transparency and openness. If a constituent comes to her for an agenda item, she wants to be able to agendize the item whether or not she agrees with the request. Member Fairchild said by having a co-sponsor it prevents an agenda item from coming forward that no one else wants to address or discuss. It brings a balance and eliminates any potential for a political agenda. It ensures a transparent and balance process. Member Giunchigliani said with any public agenda, political items are always a possibility. She said there’s never been an issue of which she is aware. Member Eliason said this has occurred in his jurisdiction, particularly around elections. Member Christensen asked how the situation would be handled if a constituent had a complaint, and if a discussion would need to occur with another Board member in order to have a co-sponsor. He asked if constituent complaints would be handled differently. Chair Strickland said another alternative exists, with a provision of having an agenda item to discuss whether or not the item should be discussed at a future meeting if no co-sponsor could be obtained. Member Onyema said any agenda item brought forward must be relevant to public health, not political issues. The process must streamline what issues can be brought forward, including being relevant to the function of the Board of Health. Chair Strickland said this issue should be resolved if the agenda item request needs to go through both the Chair and Dr. Sands. The member requesting the item would trust the Chair and Dr. Sands to put forward only appropriate items. Any items unrelated to the Board’s mission would be deemed inappropriate. She asked if the Chair and/or Dr. Sands would have “veto” power and if an appeal process were warranted. Member Jones said historically most agenda items have come through staff, and those items from Board members have come through staff as well. Today the Board is looking at adding a


layer of including the Chair in the process, which provides another layer of protection. This is also a mechanism to ensure political agendas from coming to the Board of Health agenda. He expressed support for agenda items coming through the Chair in collaboration with staff. Member Giunchigliani noted members of the public can request items through public comment, which would be agendized through the Chair and Dr. Sands. The requests would be in writing, and the Board could be notified that an agenda item request was made. This would allow for complete notice and disclosure and if there is a potential for a political agenda, everyone is aware and the Chair can make a decision on whether or not to agendize the item. Member Eliason suggested that since the Chair is receiving the request the Chair is then the co-sponsor of the agenda item. Member Fairchild said there must be checks and balances in place and this option satisfies that need. Chair Strickland asked if the Board were in favor of this option and asked for a motion. She said a policy statement will be created and will be shared with all Board members, including new members as they come on board. Member Fairchild suggested including a provision that the agenda item request must be relevant to the duties and responsibilities, or the mission statement of the Board of Health. Member Giunchigliani said a member of the public may request an item that is not relevant to the Board of Health, but is still important to that person. Member Fairchild noted if the request is beyond the purview of the Board she would have trouble bringing an item forward. Member Giunchigliani referenced the gentleman who had concerns with pools and asked for the Board’s assistance. Member Onyema clarified that Board member requests for agenda items would be given to the Chair and Dr. Sands. If the Chair asks for an item, it will be given directly to Dr. Sands. Dr. Sands said he wants to prevent staff from being in the middle of a discussion about possibly denying an item from coming forward. He noted that everyone’s time on the Board is valuable and as the Board only meets once a month often times the agendas are quite lengthy. There needs to be a process in place so the Board can determine what items they wish to hear and devote time to discuss, particularly in relation to the mission of the Board. Member Giunchigliani said an agenda item could be included at the end of the agenda for new business and issues for future agendas. Chair Strickland said she does not want to stand in the way of items coming forward if the Board feels a particular item is worthy of consideration. With this potential agenda item, it allows for the Board to bring up in public meeting those items they wish to agendize. Member Tarkanian said the agenda item in the City of Las Vegas refers to issues being discussed by other Boards or in their respective areas. However she has asked for agenda items from time to time. Member Eliason said in North Las Vegas they are considered Council Items, and issues are discussed but no action is taken, other than to agendize for a future meeting. Member Giunchigliani said this would be worthwhile, as Member Menzel could have issues or activities at UNLV of which the Board should be made aware. If there’s no agenda item, how can the discussion occur. Perhaps a future agenda item would occur, other times not.


Member Anthony noted the agenda item requests will go through the Chair and Dr. Sands for vetting and once on the agenda the Board will discuss. Any irrelevant items will be on the agenda and the Board can choose whether or not to discuss. The Board needs to trust each other that only relevant issues will be brought forward. Chair Strickland summarized that all requests for agenda items will be submitted ten (10) business days prior to the next meeting, and must be submitted in writing to both the Chair and Dr. Sands, and all items must be relevant to the mission of the Board.

A motion was made by Member Jones to create a Board Policy concerning the requests for Board of Health Agenda items which must be 1) submitted ten (10) business days ahead of the Board of Health meeting, 2) submitted in writing to the both the Chair and the Board’s Executive Secretary and 3) must be relevant to the mission of the Board of Health; seconded by Member Menzel and carried unanimously.

Chair Strickland said staff will prepare a document for the Board’s review and consideration for approval. Member Giunchigliani asked if any Board Policies were in existence. Dr. Sands said this would be the first. She suggested that Board members work with Mrs. Clark and staff to review past Board actions to build future Board Policies. Chair Strickland asked for a motion to include a new agenda item to address future items and Board comment. Member Christensen said this would require Board members to stay to the end of the meeting. The item will occur at the end of the agenda.

A motion was made by Member Christensen to include an agenda item to address Board issues and requests for potential agenda items, which will be the last agenda item; seconded by Member Giunchigliani and carried unanimously.

2. Discuss Legal Basis for Board of Health Members Voting on Fee Increases and/or

Budgetary Items (requested by Chair Strickland)

Chair Strickland said there are several policy-related items on the agenda today. She said she wanted this issue to be discussed because there have been comments by Board members as to not allowing non-elected Board members voting on fees increases and budgetary items. She said there is a legal basis as to why non-elected members can vote on Board items. She asked Stephen Minagil, board legal counsel, to address this issue. Mr. Minagil noted at the request of the Chair he reviewed all applicable statutes. The Nevada Revised Statutes (NRS) indicate no distinction between non-elected members voting responsibilities except for the selection of other non-elected members – this is the only distinction in statute between elected and non-elected members’ voting responsibilities and powers. There is a reference in NRS 439.336(3) which references the affirmative vote of all members, with no distinction between elected and non-elected members, in adopting regulations. The legislature said all members, whether elected or non-elected, should have the same voting responsibilities. There is another statute which refers to this Board having the same privileges, duties and powers as a county board of health. In NRS 439, the legislature created district boards of health in counties with populations exceeding 400,000 and made only one distinction in voting rights and powers of elected and non-elected members and that is the selection of non-elected members. Mr. Minagil said it is his opinion that non-electeds have the same voting powers as elected members in all voting matters, including regulations and fees.


Member Anthony said this is good information, but philosophically all Board members are equals and there should be no distinction in voting on any item. Chair Strickland expressed her support for this comment and noted she sought to ensure other Board members were on the same page. Member Vigilante said by not allowing non-elected members to vote on fees and budget items it defeats the purpose of having non-elected members on the Board. Member Fairchild suggested this be the second Board Policy statement. Mr. Minagil said it is the law and a policy is not necessary. Member Fairchild said by having this statement in writing, it reinforces the Board’s position and support of the law. Member Christensen said this issue has come up several times. Member Anthony asked for clarification on the one time on which non-elected members are unable to vote. Mr. Minagil said only elected members of the Board can select the non-elected members – this is the only distinction in voting powers as defined by NRS. Member Giunchigliani suggested including in the policy statement that pursuant to NRS 439, all members are equal in voting except for the distinction of selecting non-elected members of the board.

A motion was made by Member Fairchild to develop a Board Policy to affirm that pursuant to NRS 439 all Board members enjoy the same voting rights and privileges with the exception of the selection of non-elected members, which is done solely by the elected members; seconded by Member Christensen and carried unanimously.

Chair Strickland thanked the Board for their indulgence in creating policy. She asked if the Board would be amenable to hearing item #4 prior to the next agendized item, as she felt the discussion on consolidation should precede the discussion for a new facility.

4. Discuss the Board’s Position on Consolidation and Providing Community-Based Services (requested by Member Giunchigliani)

Member Giunchigliani said following the last Board meeting she was alerted by another Board member that Senator Parks had requested a BDR for possible consolidation (BDR 368: authorizes reorganization of public health function of district health departments in larger counties). She said the Senator has not drafted language to date; he would like to hear from the Board relative to this issue. She shared copies of the proposed legislation, SB322, from the 2009 session for the Board’s understanding of the co-location/service concept (attachment #1). Chair Strickland also had discussion with Senator Parks. Member Giunchigliani said SB322 was modeled after the San Diego model. She would like to have conversation as to how service delivery should come about. There will be legislation forthcoming. All jurisdictions were required to submit information about consolidation. There is proposed language for consolidation of fire services throughout the county. The public expects the jurisdictions to look at sharing services and creating efficiencies. Consolidation does not always save money, but there could be better ways to deliver services. She referenced the efforts of the Southern Nevada Regional Planning Coalition have resulted in some consolidations. They are currently looking at business licenses and the ability to go to one office and pay fees, and the county would issue the business license – the same ordinances and rules should apply throughout the county regardless of where the process starts. It should not be cumbersome for business to occur. She noted that it is a lengthy process and it is difficult to change culture and policies. Something is going to happen and she feels the Board


should be part of the discussion, versus reacting to it. She suggested sitting down with the Senator. She said we need to define community services and how to better serve the community, versus the perception of the county taking over the health district. She suggested co-locating with UMC or developing a clinic model within in the school district using public health nurses. We need to determine where services are fractionalized. The issue should be diverted from consolidation to a service-oriented model. As of today the BDR language is a blank wall and the Board should be part of the process. Member Eliason suggested a Board committee sit with Senator Parks to discuss the BDR and include staff in the discussion, and come back to the full Board for further discussion. Chair Strickland said the Board needs to determine its position on this issue. Currently the district operates with strategic locations with greatest reach, with one central location for administration and additional clinical services. If the county or legislature is considering consolidation in terms of the San Diego model and being more in the community, there would be a different approach than what exists today. The Board needs to express its views in one voice to the legislature, versus one or two Board members providing opinions. Member Eliason said the district is out in the community now. He asked what we are trying to change. Chair Strickland said there have been discussions about consolidation, and Member Tarkanian said the district is out in the community and the schools providing services. There has been no vote of the Board where a position is stated and that that voice should go to the legislature. The Board needs to agree upon the best delivery of service, which is one administration office with strategically located clinics for service delivery, and take that statement to the legislature (attachment #2). Member Tarkanian said the model does not have to be consolidation, but shared services. Member Giunchigliani said she believes in shared services. Consolidation scares people due to the perception of “taking over.” She said the original intent was a community-based delivery system, but she feels it has not been fully capitalized. She said we could already be doing certain things and others may not be aware the services are provided, but there is always room for improvement. Chair Strickland asked if the current approach is the best or should we be doing something different. She expressed support for the formation of a committee to meet with Senator Parks to discuss the ramifications of the bill. She asked the Senator if he thought the final result of the bill could be the health district being consumed with the county and he said this would be a possibility. This would put the health district under complete county control. She said having served on the Board for three years, she has respect for the Board and how the health district operates. She said it is not that the county does not operate well – she feels the health district operates very well and sees no point in changing something that, in her opinion, works. She said this could change if the Board does not express its feelings in one voice to Senator Parks. Member Tarkanian asked if there is a way to determine how well the district is doing something now and how services could be better provided. There is always room for improvement. She said the district is doing an excellent job; she expressed her disdain for consolidation, particularly because it does not always save money and does not always provide for better services. She expressed her belief in shared services and resources. Member Giunchigliani said she wanted the Board members to see what was being discussed in the last legislative session to see where the potential thought processes were headed. There could be a better approach to service delivery. The Board needs to identify what the view of the


health district is and what services are not being provided, as well as what can be improved. She agreed meeting with the Senator is a good option and reporting findings back to the Board. Bill draft language is due in February and there is still time to have meetings and discussions. She said staff should be included in these discussions. Member Christensen said public health is nebulous and is completely different from visiting a doctor. Public health is a completely different product and the term “health” seems to be problematic for some, which brings to mind a different model. Public health encompasses numerous components that do not fit in a traditional service delivery model. Social Service works hand in glove with staff, as noted by Member Giunchigliani; however she does not want the public to have to go to several locations and complete tremendous amounts of paperwork to receive similar services. We need to explore avenues to make receiving services more efficient and better for the client versus the district. Member Christensen said Member Giunchigliani makes some good points, but we need to step back and look at the larger picture. We need to determine how the local board of health fits into the state-wide public health picture. We need to look at the 50,000 foot level and determine if we are being the best partner to the citizens of Nevada and helping with outreach to all communities. If there is to be discussion about co-location and shared services we need to have the discussions on both the micro- and macro-models. Member Giunchigliani said Richard Whitley, administrator of the Nevada State Health Division, may want to be involved in discussions as well, due to potential cost-shifting to Clark and Washoe Counties. She suggested an arrangement for direct funding from CDC to the district. Member Christensen said the local health authorities are Clark, Washoe and Carson City – the state health division covers the frontier and rural areas of Nevada. Member Onyema said Board members may not truly understand the function of the health district and may require some education regarding operations and services. We need to find out what we are doing and where we need to go in the future. Some formal education is required before the Board can make an affirmative statement. Chair Strickland noted if the Board is to be proactive and stay ahead of the curve then everyone should be well-informed in order to make a legitimate and reasonable argument to support the Board’s position. The Board needs to be well acquainted with all the intricacies of district operations in order to form an affirmative statement. She said the Board seems receptive not only to forming a committee to meet with Senator Parks but to receive education from staff in terms of district operations and functionality. Dr. Sands noted other health departments, as well as the county, have done retreats or advances. If the Board is willing to devote time, staff can arrange an educational session. This will help Board members have a full understanding of not only what the health district does, but what public health services are and how they differ from health care services, as well as how the district delivers services in southern Nevada and how we work with our various partners to assure delivery of services to the community. Member Christensen further suggested having a portion of each meeting devoted to the diversity of what the district does and provide continuous education to the Board. This type of rolling agenda keeps all Board members informed and current on all issues. This format is being adopted by the Board of Medical Examiners.


Member Giunchigliani agreed with the concept of an annual retreat, to coincide with the seating of new members. She also expressed interest in the rolling agenda item to focus on different programs and services, and to include our outside partners. She said staff may have more collaborations that the Board realizes. The Board needs a better understanding of how the district works and what services are delivered and why. She said services may have been cut from the budget several years ago and perhaps those services are truly needed in the community and should be reevaluated. Member Jones said the informational items now contain this information, but he suggested an expansion of this area. He said the committee should focus on the true mission of the health district. He said the real danger in proposed legislation is consolidation of services that are not part of the public health, such as social services, into one organizational structure. The health district and the Board are efficient because of its mission and not trying to be all things to everyone. Chair Strickland confirmed the formation of a committee to meet with Senator Parks. An informational retreat will be held on site annually for Board members. From these meetings the Board will have the knowledge and wisdom to set forth an affirmative Board position statement to clearly relay to the legislature how the Board feels about the situation. Member Giunchigliani said at the educational meeting or as part of the rolling agenda, a flow chart of services and delivery would be beneficial, including where services are offered and the target client base. She further suggested the Board members visiting each location as time allows. She said there are some county buildings and offices where commissioners have never been and she asked how a Board can operate if they’ve never visited all locations where business is conducted. She said we also need to identify services which are no longer offered and evaluate if the district should again provide those services to the community. She would like to see more engagement of the Board in these discussions, including give and take with staff. Member Vigilante said he is very familiar with the duties of the environmental health specialists and their jobs entail more than inspecting restaurants. He said he is not familiar with the clinical and nursing services and would like to know what it is exactly that staff does. He said by spending time with staff the Board can better understand what services are offered as well as the job each staff member does on a daily basis. Member Giunchigliani said staff is the Board’s face to the public. The Board needs a better understanding of staff’s duties. Chair Strickland said the motion now includes formation of a committee, establishment of an annual Board educational retreat and site visits.

(Member Menzel left the meeting at 9:30am) The informational items on the Board agenda will now be in the form of a rolling agenda item for updates and information about a particular program or section. Chair Strickland called for a motion. Member Giunchigliani said she would make a motion and asked if Board members could email the Chair of their desire to participate on the committee, which needs to be limited to six (6) participants. Member Eliason said the educational retreat should occur prior to the meeting with Senator Parks. Dr. Sands asked if the Board would have an affirmative position statement prior


to the meeting with the Senator. Chair Strickland said natural progression is to have the educational retreat, meet with Senator Parks, come back as a full Board and discuss the information received, and then make a unified affirmative position statement for the legislature. Member Jones expressed his desire to participate on the committee, as did Members Christensen, Vigilante, Fairchild, Giunchigliani and Tarkanian. Chair Strickland asked for members to email her indicating their desire to participate on the committee.

A motion was made by Member Giunchigliani to 1) form a committee of no more than six (6) members to meet with Senator Parks, 2) establish an annual Board educational retreat to include site visits, 3) form an affirmative Board position statement on district services and operations, and 4) expand the informational items on the agenda to a rolling agenda format to include updates and information about particular district programs and sections; seconded by Member Anthony and carried unanimously.

(Member Menzel returned to the meeting and was seated at 9:33am)

Dr. Sands noted one of his goals is to continually update the Board on our services to the community and how those services are provided. He referenced the Annual Report to the Community, which is prepared by the Public Information Office and he noted the outstanding work by staff in putting the report together, which though an overview provides a good description of the services provided and our locations. He encouraged all Board members to acquaint themselves with the publication. Member Giunchigliani said the document is very helpful and references it in her constituent newsletter. The document is available on the district’s website at http://www.southernnevadahealthdistrict.org/stats-reports/community-report.php. A link will also be provided on the Board’s website for Board members to access the document. The district’s website is also very rich with information (www.snhd.info). Dr. Sands asks his students to familiarize themselves with the website prior to starting their rotation to have a better idea of the work of public health and the services provided by the district. Dr. Sands explained that what we do in public health is everything that cannot be done in a doctor’s office. There is a lot more to health than just what happens in a doctor’s office or a health facility – it is the responsibility of a public health agency to take care of those items and issues. Many health departments and districts are designed with a flexible model with sites and structures strategically placed in the community to reach target populations, coupled with outreach programs which allow for flexibility that if needs changes in the community the services can be provided where needed. Needs changes over time, including services being provided by other agencies or partners, which allow the district to provide other needed services to maximize our resources. Member Giunchigliani noted she includes the information received from Mrs. Clark and Ms. Sizemore in her newsletter. She asked for one sheet from each program/section which depicts where they are located. Part of what would help the Board is to look at the services being delivered and if there are ways to capitalize upon them. We need to look at any barriers which may be bringing down the immunization rates. If we are looking to get rid of health cards we need to examine the purpose of the program and what can be done to ensure it is operating efficiently, including the education component. We need to find ways to remove barriers to help the community find employment and meet the requirements of those jobs. Member Tarkanian said a local senior home is requiring a health card in order to use the kitchen facility. She said there are barriers in the way of allowing people to be more effective and lead full lives. This is a requirement of the establishment’s management and not the health district.

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Member Menzel said we are getting down to the micro-level and we need to look at the responsibilities of the Board of Health. Some activities occur in order to meet our main objectives. We should start there and determine the purpose and rationale behind the program, be it surveillance, assurance or the like. By starting with the framework of what we are trying to achieve and the defined outcomes as compared to other communities we will better determine if there are true barriers and roadblocks.

(Member Onyema left the meeting at 9:40am) Member Giunchigliani said as an elected official she has to react to things that non-electeds do not, particularly certain requirements for licensing, permits or health cards. If an elected is not aware of a certain requirement, it creates problems. They have to deal with the bureaucratic perception, though there may be a legitimate reason for doing something, but the Board must know the reason why and how. We need to know why health cards are required and why they were implemented originally. Member Menzel said instead of having nursing staff specify where each clinic is located, we should tie the services back to our main purpose and why those services are offered. This could help explain the “why” to constituents. Member Giunchigliani said she would like to see both, as it makes better sense, and provides a more inclusive model. We should not forget the public purpose which drives why we are doing this service. We can then analyze whether or not this was the best way to deliver the service.

(Member Onyema returned to the meeting and was seated at 9:41am) Dr. Sands said staff has been reviewing the health cards program and looking for ways upon which we can improve, including clarity of its mission and a more efficient and effective delivery of service. There are many business operators who require a health card as more of a validation or assurance that the employee has received education from the health district. Member Tarkanian said to look at all sides, both from that of the district and the elected officials, and tie it to the organizational structure, so as not to be so bureaucratic that it affects individuals. Chair Strickland said with the educational retreat Board members will have the basis to discuss why things are done a certain way and how we can make improvements. There is the option for the Board to meet prior to the committee meeting with Senator Parks as well to ensure everyone is on the same page. The affirmative Board position statement will be expressed following the meeting with the Senator. Member Giunchigliani asked Dr. Sands if he still meets monthly with staff. Dr. Sands said the “Breakfast with the Boss” meetings are held quarterly due to waning interest in participation. Dr. Sands said he also visits each location periodically to meet with staff. Member Giunchigliani suggested Board members join in on the employee meetings as their schedules allow, or to have a separate meeting with employees. She would like to hear from employees.

(Member Eliason left the meeting at 9:45am)

3. Receive Update/Report Regarding Replacement of the Main Facility as Requested at the August 26, 2010 Board of Health meeting; Discuss the Impact Potential Legislation may have on the Board’s Decision on a New Main Facility; Direction to Staff

Chair Strickland said she enlarged the scope of this item to address the potential impact of pending legislation to put in the Board members’ minds if the health district will fall under the auspice of the county is there truly a need for a new main building. The county could have other ideas as to how this should be handled. We also need to consider moving to a new facility


when current economic conditions afford less expensive facilities. We don’t know what the legislature plans to do with the health district, and we need to determine what the best options are in terms of a building. Scott Weiss, director of administration presented on this item. The appraisal process has been started, as requested by the Board, and will be completed by the next Board meeting. The architects have also commenced the due diligence process, which will also be brought to the Board at its next meeting. The Board requested clarification on the different funds that comprise the district’s budget. Mr. Weiss shared a brief analysis to better define and explain the funds (attachment #3). The numbers presented are based on initial figures from the audit which is currently underway – the audit will be completed and presented to the Board in November. At present all numbers are estimates. A fund balance, regardless of which fund is being discussed, is similar to a checkbook – money comes in and goes out and at any given point in time the balance fluctuates. The district’s general fund is the fund which maintains all money in and out, and this number can change from day to day depending upon revenues received and expenditures made. Sound accounting and budgeting practices are to maintain positive fund balances, which are reviewed annually during the audit. All Board members and the public receive this information as part of the Comprehensive Annual Financial Report (CAFR) each year. All information is very transparent with the opportunity for questions. The general fund is the cash account for the district – this is the account where all monies are received and expended. Within this fund there are multiple components, including unreserved/undesignated balance and the reserved balance, which is committed for various specified purposes (inventory, prepaid items and encumbrances). Additionally the district maintains several other funds including the Bond (debt) fund, Capital fund, Workman’s Compensation Self-Insurance (liability) fund and the Proprietary fund (SNPHL). The Board approved a district policy to maintain the general fund reserve (unreserved/undesignated) between 11.66% and 25% of the total expenditures. The purpose for maintaining this level is:

• To protect the district’s essential services, programs and funding needed during an economic downturn

• To ensure there is adequate cash to cover the district’s cash flow requirements, as well as

o Public health emergencies o Contingencies o Unexpected declines in revenue o Unexpected large one-time expenditures o Future funding of non-operating expenses such as

Capital fund – asset maintenance/replacement (direct funded from general fund)

Bond fund (direct funded from general fund) Workmen’s compensation self-insurance fund (direct funded from general

fund) Proprietary fund (SNPHL) Pensions and other post-employment benefit

• Compensated absences


In regards to the unreserved/undesignated fund, at the conclusion of FY09 there was a balance of $25,177,271. This represents:

a) 38% of the total general fund expenditures of $65,882,783 (cash basis accounting), or b) 30% of the total expenditures of $83,855,651, including $8,525,670 of transfers

The bond fund was initiated to cover the debt for a new facility is based on .25 cents of the 3.50 cents per $100 of assessed value, which is the district’s allocation of property tax, as authorized by statute. This fund was approved by the Board of Health on March 27, 2008. At the end of FY10 this restricted fund had a balance of $8,899,272. An additional $1,524,493 will be transferred by the end of FY11, which was approved in the current budget. The capital fund is provided to meet capital needs, both known and unknown, such as new and replacement equipment. The allocation to this fund is part of the annual budget process. There is no defined formula, but is based on the district’s needs. The current budget provides for $2,243,864, including approximately $1.4 million for the VAX hardware replacement (Decade Solution). At the end of FY10 the capital fund balance is expected to be $3.6 million, which is based on the accumulation of approved budget allocation(s) that was not expended by the end of the fiscal year. The worker’s compensation self-insurance fund allows the district to be self-insured for workman’s compensation and a policy is maintained above the $400,000 retention. The reserve is based on an actuary each year. This fund was approved by the Board May 26, 2005 and the Division of Insurance on May 12, 2005. At the end of FY10 the fund balance was approximately $263,000. The proprietary (enterprise) fund for the Southern Nevada Public Health Laboratory (SNPHL) was established by the Board in March 2004. At the end of FY10 the fund balance is expected to be $3 million, and the balance covers the ongoing operations and ensures the capability to meet the cash flow needs in case of:

• Public health emergencies • Contingencies • Unexpected declines in revenue • Unexpected large one-time expenditures

Chair Strickland asked if the four funds just described totaling approximately $15 million is part of the $32 million. Mr. Weiss said this is in addition to this amount. The general fund balance is estimated to be $32 million as of June 30, 2010. Additionally the following funds will have estimated balances as outlined:

• Bond fund: $8,899,272 • Capital fund: $3,600,000 • Self-insurance fund: $ 263,000 • Proprietary fund: $3,000,000

This equates to approximately $47,000,000 in total between the five accounts. The bond, capital, self-insurance and proprietary funds are restricted as approved by the Board. Of the anticipated $32 million in reserve approximately $31 million will be considered unreserved/unrestricted. The expenses, including transfers, are expected to be $70 million, which is subject to the completion of the FY10 audit. The approved FY11 budget included an


anticipated beginning fund balance of $25 million, with approved transfers of $6.1 million, which brought the ending fund balance to $18.9 million. In previous meetings, some Board members alleged the district was taking money from reserve accounts to pay operating expenses and bills. At the end of FY11, with an anticipated beginning fund balance of $31 million and approved transfers, the expected ending fund balance will be approximately $25 million. There was a slight increase over the last year due to salary savings from not filling vacant positions, as well as other realized efficiencies. Member Vigilante said he continues to be confused on the distinction between the general fund and the reserve fund. He was of the understanding that the Replacement Facility Committee had asked to have these items separated. He asked from where the term “reserve fund” comes Mr. Weiss responded this is the undesignated/unreserved portion of the general fund, which is $31 million of the $32 million. Mr. Weiss said the CAFR will depict the actual monies in the general fund, as well as breakdown of the unreserved/unrestricted portions. Mr. Weiss said the general fund is one account with specific designations for certain portions of the money. Member Vigilante said he wanted to clarify a few additional items for his own understanding. He referred to the capital fund and asked about equipment and the environmental health division. Mr. Weiss said the approved FY11 budget includes funding in the capital fund for the Decade Solution hardware for the VAX replacement. Capital, as defined by NRS, is anything over $3,000 that has a useful life. Member Vigilante asked if the Board had objection, or if anyone wished to join him, in meeting with Mr. Weiss for a more detailed discussion on the composition of the budget. Member Giunchigliani asked if the budget committee had been reorganized. As the responsibility falls under the scope of the audit committee, she asked that Mr. Weiss meet with Ed Finger, the comptroller and George Stevens, the county’s chief financial officer to ensure everyone is on the same page. She said they mentioned a concern to her about the reserves and that if they had known the anticipated balance of this fund, the county would not have allocated as much property tax dollars this year, which was close to $10 million, and this money could have been given to Social Service or another agency. She said they were told the reserve level was at $25 million, not $32 million. She would like for the county financial team to hear this analysis as well. Mr. Weiss said they will also receive a copy of the CAFR. He said that counsel will need to discuss the property tax allocation as defined by NRS. Member Giunchigliani asked for the balance in the investment fund and the growth over the last year. Mr. Weiss said the investment fund is all the funds put together – by statute there are separate funds maintained by the county treasurer and they are invested. Interest is accrued on these accounts as well, and for FY10 the anticipated interest was just over $1 million; FY09 interest was $1.5 million as the interest rate was higher. The interest from the general fund is recorded back to operating revenues. Member Giunchigliani said the Board could designate the interest to be used for nursing services or another area versus going to the general operating expenses. Mr. Weiss said the Board can make its own decision; however when the budget is brought to the Board for consideration staff tries to match operating revenue and expenses for a balanced budget. The $1 million in earned interest for FY10 is applied to the FY11 budget in order to achieve a balanced budget. Member Giunchigliani said the Board could make a policy to use the interest for a more specific purpose. Mr. Weiss said the effect would be the Board authorizing staff to take money from the reserves each year to fund operations. Member Giunchigliani said people do not pay taxes solely for those funds to sit in a savings account and no delivery of service. If the interest is directed to a specific service, another service could be reduced. Member Giunchigliani said monies could be directed from the capital fund and general funds could still be used for delivery of direct services.


Member Giunchigliani asked for clarification on the reserve accounts, including the $1 million designated/reserved portion. Mr. Weiss said the numbers were provided by the auditors this week, however they are still estimates as the audit is not complete. The CAFR will be completed in November and come to the Board at that time. Member Giunchigliani asked for an exact amount of cash on hand. Mr. Weiss provided the average balance as provided by the county at the end of August, which is as follows:

• General fund: $36,500,000 • Capital fund: $ 3,400,000 • Bond fund: $ 8,900,000 • Self-insurance fund: $ 466,000 • Proprietary fund: $ 3,300,000

Member Giunchigliani asked how this information compared to the information presented in the fund analysis just presented and why there are differences. Mr. Weiss said the numbers from the presentation reflect the balances at the end of FY10. Each month the actual numbers go up and down depending upon monies in and out, and the balances provided from the county are average balance as of end of August. Environmental Health receives most of its revenue at the start of the fiscal year, due to the billing cycle, and from a cash perspective the July balances are low and the high points are in August and September; the balance goes down from there as bills are paid from the collected revenue. Member Giunchigliani asked for clarification on the capital fund, as it was approved at $2.7 million. Mr. Weiss said the budget for FY11 was approved at $2.2 million and unspent dollars from the previous year roll to the current year’s fund. There is currently a balance of $3.6 million, which includes an accumulation of unspent dollars from previous years. Member Giunchigliani said the county may examine the increase in the ending fund balance, which is close to $10 million higher than anticipated. Mr. Weiss said it is closer to an increase of $6 million. Chair Strickland said if the county is going to have an issue with the allocation of funds to the health district, and if there is a disagreement in the interpretation of the NRS, the Board needs to be proactive in dealing with the issue. She agreed that it would be worthwhile for Mr. Weiss to meet with county financial staff to air their differences. Her concern is that if our allotment decreases, though we’ve based on our budget on the higher amount, we will have based our budget and programming on funds we will not receive – our job is to provide services to the community and if these services are interrupted we will have a larger problem on our hands. Chair Strickland noted she would entertain a motion to direct Mr. Weiss and his staff to discuss the funding allocation to the health district with county financial staff and reach an understanding. Member Giunchigliani made the motion and suggested that up to six (6) Board members be allowed to attend this meeting as well. Member Vigilante seconded the motion. Member Vigilante said as a new Board member and coming from industry, his role is to understand the entire atmosphere and how everything works. If he lacks understanding he will go to the appropriate person for clarification. He continues to be unclear on the reserve funds and would like additional information. Member Jones asked for clarification on the increase to the general fund balance. Mr. Weiss said it is due in part to the H1N1 grant funding – many programs did not expend the 8010


dollars allocated for certain services as employees’ time was spent on H1N1-related activities and this generated savings in 8010 funds. There was also a projected savings of $3.2 million realized in unfilled vacancies as of September 2009. Most of the district’s spending is done in the latter part of the fiscal year; the budget brought forward for approval annually in March is based on February’s projections and not the full expenditures through the end of the fiscal year. Mr. Weiss said that all grants are reimbursed to the district. As the district spends time and money on services and contractual services related to H1N1, the district fronted the money for ninety days until federal reimbursement came in. The cash flow varies from month to month as money is spent and federal grant reimbursement arrives. This is also what is occurring with the large Communities Putting Prevention to Work grant – the district provides money upfront each month and waits for reimbursement. The district continues to look for efficiencies and cost savings in programs and services as well. It is anticipated that it could be as long as four years or more before we realize the same funding from property tax allocation as we did prior to the economic downturn. Revenues may decrease, and we want to keep ongoing operations running smoothly and efficiently to provide essential public health services to the community. Chair Strickland said she does not want to be in the situation where we must become less efficient and spend more money to ensure we receive our full property tax allocation from the county. She said there is a game in government that you must spend your allotment or you may lose it, and therefore spending occurs in a wasteful manner. She feels this is a poor approach for any government agency. Mr. Weiss thanked staff for realizing cost savings and efficiencies across the district. He said it is by the efforts of staff that the district has been able to identify opportunities for savings.

A motion was made by Member Giunchigliani to have Scott Weiss and staff meet with financial staff from Clark County to discuss the dedicated funding stream as defined by NRS 439.365 to come to a clear understanding on the amounts and air differences, and up to six (6) Board members can participate; seconded by Member Vigilante and carried unanimously.

Member Giunchigliani noted staff was doing due diligence process and asked for clarification on this process. Mr. Weiss said our architects are reviewing the structural components of the building in response to questions raised by the Board at the August meeting, as well as a mechanical review to ensure the air conditioners were replaced as noted on the specifications and the remaining warranty measures. Space planning updates are also underway. Staff plans to bring this information to the Board at the October meeting and answer any additional questions which may arise. There may be some other options available to the Board as well. He hopes that the Board will vote one way or the other so we can begin funding a building. Jeff Gerber of PGAL stated his firm has contracted with both structural and engineering firms to ensure the integrity of the building. They are also conducting an ADA review as well. Chair Strickland said the Board will wait for additional information from staff at the next meeting. She asked if any of the Board members are concerned with the prospect of purchasing a new building. Member Giunchigliani said her concern is long-term debt financing and staff needs to speak with George Stevens about debt service and actual cost. If there are legislative changes it could be problematic. She agreed that a new facility is needed, but the proposed building may not be the best option. Member Jones agreed the current facility is not serviceable for long-term needs. There will be expenses coming whether for a new building or to maintain the existing one. Regardless of any


legislative changes forthcoming the health district needs a home whether it is under a county or independent umbrella.

5. Receive Update on the 2010 Employee Satisfaction Survey; Direction to Staff (requested by Member Giunchigliani) Member Giunchigliani noted the district is conducting an employee satisfaction survey every other year. She said when Dr. Sands’ evaluation was being done she was unaware the survey was underway, and she had wanted the results at that time. Scott Weiss, director of administration and Norine Clark, chief steward updated the Board as to the current employee satisfaction survey. Mr. Weiss said the Joint Labor/Management Committee (JLMC) met earlier in the week to review the comments. Over the next two weeks, the analysis of the year-over-year will be completed and the JLMC will review the numbers from both surveys. The intent is to review the 2007 and 2010 data and determine where improvement has been made, where improvement is lacking and determine an action plan to address those agreed upon issues. Ms. Clark said labor and management are working in concert to review the study results. There is a large amount of data to review and Brian Labus has been working on the analysis amongst his other duties. A thorough review will be completed, including an analysis for any changes in data. The goal is to ensure that all employees are heard and that any issues and concerns voiced through the survey are addressed appropriately. This is an improvement tool for both the employees and the district. Member Giunchigliani thanked staff for the information. She expressed concern in waiting a long period of time before addressing any concerns brought forward by the survey. She asked for clarification on the analysis of the data and comments. Mr. Weiss said the survey is a quality improvement tool and not a mechanism to punish management. The comments are being reviewed to ensure personal comments are not made public to employees. The comparisons under review are from data point to data point. Ms. Clark said there are questions specific to department with a ranking scale as well. Member Giunchigliani asked if the Board can receive a blank copy of the survey so Board members know what questions were asked of staff. Ms. Clark said all information will be provided to the Board by the next meeting. Member Giunchigliani asked that Board members be allowed to view the unredacted copy of the survey results as was done previously, and she asked Mr. Minagil to review how this was handled previously. She asked Dr. Sands, based on comparisons, if his team would determine a plan of action to bring back to the Board to address both good and negative issues. Dr. Sands indicated that a plan would be done and could be presented to the Board if that is their interest. An action plan will be developed for items to be addressed by his team, as well as those to be addressed on a more individual basis. Ms. Clark said the JLMC will also address issues coming forward from the survey. Chair Strickland noted the October meeting has a lengthy agenda. If this item comes forward in October, it will be a very long meeting. It is important to hear this information. She said it is important to note that as a Board they set policy, but personnel administration is the role of Dr. Sands as the chief health officer. The Board can provide policy instructions and guidance but it is his responsibility to implement those suggestions. The Board must ensure it is functioning within its role and not interfere with Dr. Sands’ role as administrator. She asked staff to provide a copy of the blank survey to the Board.


Dr. Sands said when the results are published, a blank copy will also be provided to the Board. The survey is administered online via Survey Monkey. Member Fairchild asked if there were questions specific to each division. The survey was a standardized format, similar to one administered in Maricopa County. There are some open-ended questions. The only specifics are line of management, so one division cannot comment on the management of a different division.

IV. PUBLIC COMMENT

Public Comment is a period devoted to comments by the general public, if any, and discussion of those comments, about matters relevant to the Board’s jurisdiction will be held. No action may be taken upon a matter raised under this item of this Agenda until the matter itself has been specifically included on an agenda as an item upon which action may be taken pursuant to NRS 241.020. Chair Strickland asked if anyone wished to address the Board. Cara Evangelista, vice president for the union, addressed the Board. She expressed her support for the Board visiting the different locations and observing firsthand district operations. This would allow the Board to see the impact of the hiring freeze, as well as adjusted work schedules. Employees are making sacrifices for public health and the district. It would be a morale booster to see Board members in the field, and how each employee is protecting the public. This would also allow employees to share important issues with the Board. She invited Board members to attend both large and small staff meetings, which are held regularly. She also invited Board members to shadow employees during inspections and other events for a better understanding of what each employee does on a daily basis. Chair Strickland said this is a second component of the educational Board retreat. Chair Strickland asked if anyone else wished to address the Board. Seeing no one, she closed the Public Comment portion of the meeting.

V. HEALTH OFFICER & STAFF REPORTS

Chief Health Officer Update Dr. Sands noted he was accepted into the 2011 Leadership Las Vegas class. He will be attending the gateway meeting September 30 – October 2 at Nellis Air Force Base.

(Members Anthony and Onyema left the meeting at 10:34am) For the eighth year in a row, financial services received the certificate of achievement for excellence in financial reporting, which is a high achievement. The district recently received a second Communities Putting Prevention to Work grant in the amount of $3.8 million to assist in preventing obesity. Deborah Williams, manager of chronic disease prevention and health promotion, informed the Board that an application was submitted in November 2009 and received word in March 2010 that we would only be funded for the tobacco prevention piece. The Department of Health & Human Service announced an additional eleven communities would be funded for CPPW activities as part of heath care reform and the establishment of the public health trust fund. The district is one of only eleven communities across the nation to receive funding for both obesity and tobacco prevention efforts. She said the receipt of these grants is a testament to the efforts of her staff and the community partnerships. One of the


hallmarks of the CPPW grant awards is the demonstration of broad community support and participation. Receipt of this additional grant will allow the district to focus on policy, system and environmental change to promote physical activity and improve dietary choices as strategies to reduce obesity. Staff hopes to work with child care centers, schools and worksites, as well as with parks, trails and recreation centers to promote the trail system in the valley. Nurse Family Partnership Program Dr. Sands noted that staff asked for this update to be heard at the November Board meeting. Final Report on 2009 Novel H1N1 Influenza and Vaccination Response In recognition of National Preparedness Month (attachment #4), Dr. Sands invited Jane Shunney, public health preparedness manager and John Middaugh, MD, director of community health, to present the final report on the 2009 Novel H1N1 influenza and the district’s vaccination response (attachment #5). Dr. Sands noted the district receives funding for the Cities Readiness Initiative as part of our preparedness program to develop response plans for mass dispensing within forty-eight hours of an event. Each year a technical review team evaluates the district’s progress and capabilities.

(Members Christensen and Giunchigliani left the meeting at 10:41am and quorum was lost) Five years ago the district received a score of in the sixties and the most recent score was 92, which is excellent. The district has come a long way in our preparedness efforts and he recognized staff for their contributions. Ms. Shunney also thanked her team for their efforts. In April 2009 the Centers for Disease Control and Prevention (CDC) announced the emergence of a novel strain of H1N1 in California and Texas. The strategic national stockpile (SNS) was distributed throughout the country to provide antivirals and personal protective equipment (PPE) in local areas in the event the virus became severe and supplies of these items were depleted. The SNS is a national asset strategically located in twelve undisclosed places across the country. When the SNS is ordered, it will arrive within twelve hours. The SNS arrived with antivirals in Nevada, and specifically in Clark County, on April 30, 2009 and was repackaged and distributed to acute care facilities in Clark County by May 4, 2009. (Members Christensen and Giunchigliani returned to the meeting and were seated at 10:46am and quorum was restored)

The PPE remained in storage for later distribution if necessary. The antirvirals included Tamiflu in three different doses and Relenza. The district initiated our Incident Command System (ICS) team to manage the event on September 17, 2009. The ICS system is part of the national response framework designed for a coordinated national response if there is a large terrorist event. The first vaccine shipment arrived on October 7, 2009, and the ICS team was tasked with determining how to distribute the vaccine to the community. The district opened the first Point of Distribution (POD) at the Ravenholt Public Health Center on October 10, 2009; the last POD closed in late December 2009. The district initiated strike teams in early 2010 to continue administering vaccine throughout the valley and schools, and the last strike team finished in July 2010. The World Health Organization declared the “swine flu” officially over in August 2010. Concerted efforts in providing vaccine to the community in response to a pandemic resulted in 294,897 H1N1 vaccines administered in Clark County at PODs, schools, clinics, and private physician offices. The district conducted an after-action report to determine the strengths and weaknesses of our efforts during the event. Board members are able to view the document in the Office of Public


Health Preparedness, but it cannot be made public due to the nature of the information contained in the report. Other agencies, including Clark County, have not made their after-action reports public. An issue of making the document public is a question of whether vulnerabilities should be shared/exposed. There have been documents provided to Board members in the past with the proviso that the document is For Official Use Only (FOUO) and not to be released to other parties. The Executive Summary would perhaps be more appropriate for “distribution” and is also marked FOUO. Major strengths of the district response efforts included:

• Staff was dedicated, professional, flexible and adopted to the POD concept. • Able to adjust patient flow and clinic size on a moment’s notice • Used contract and volunteer medical and clerical staff, thus allowing SNHD staff to continue

with daily operations • Issues were resolved using the National Incident Management System (NIMS) principles • Alterations were made to plans based on public demand and new guidelines coming from

Federal and State resources • The H1N1 response provided an opportunity for SNHD to test emergency plans and

procedures during a low-stress event, so lessons learned can be incorporated into plan revisions

Areas for improvement were also identified:

• SNHD staff need more training on the NIMS principles through the Incident Command System

• Due to the length of the response, it was difficult for many staff to distinguish between their daily responsibilities and the H1N1 duties, blurring lines of communication

• To aid staff in understanding ICS/NIMS, more training and exercise opportunities using public health scenarios are needed, specifically training for Command and General staff

• Additional checklists should be developed to serve as “memory joggers” during an event/incident

• Current plans should be revised to address both emergent and long-term events, taking into consideration severity of disease to determine the level of response

The purpose of ICS and NIMS is to ensure that everyone is speaking the same language and using the same management system during an event. Staff receives training online for the basic levels of NIMS and ICS. 95% of staff has been trained at the ICS 100 and 200 levels. Member Jones noted that it is his experience that face-to-face training has been more effective at the resorts than online training.

(Member Fairchild left the meeting at 10:55am) At the district ICS 300 and 400 training is done face to face onsite and the training occurs over a four to five day period. This training is offered to management staff, as they are the most likely to hold command staff positions during an event. Ms. Shunney said this H1N1 event was very long and extended time was something we had not planned for in our preparedness efforts causing us to change our thinking and plans as the event evolved, for example we changed from POD’s to strike teams. Typically events are short scale, no more than a few weeks in duration. This event lasted almost one year.


Dr. Middaugh said the initial planning phase focused on the realization that the initial vaccine supply would be insufficient to meet the needs of the community, including the complexity of the pre-determined high-risk groups. The planning effort centered on getting information to the public and providers. Initially vaccine was targeted to the high-risk subgroups with the highest risk of mortality and morbidity. There was tremendous controversy in ways to manage flu exposure as well, which compounded the problem in providing vaccine. The elderly were not an initial priority group, which was a concern to the senior population. The elderly had pre-existing antibodies to this strain and had a far less morbidity rate to the virus than expected. The first shipment of vaccine was FluMist, which is only available for a specific group, and many members of the high-risk subgroups were excluded from the criteria. We planned to vaccinate 13,000 healthcare workers and first responders in our first POD, and only 300 people came for vaccine due to misconceptions about FluMist. As our vaccination efforts progressed, FluMist became the vaccine of choice versus a traditional shot.

(Member Fairchild returned to the meeting and was seated at 11:02am)

The outbreak peaked in late October/early November and vaccine did not arrive in plentiful supply until the peak passed. Once we received ample supply of vaccine, we began administering the vaccine to the entire population. Initially there was a large demand for vaccine when it was in short supply; once our supply increased, the demand dropped drastically. The public was able to receive the vaccine throughout the community, whether it be at the health district, a local pharmacy or a provider’s office. Our active efforts continued to focus on pregnant women and those with underlying health conditions, while providing vaccine to the community as a whole. H1N1 will continue to be the dominant flu strain for several years to come. The district administered 152,000 doses to the general population, which is only 8% of the population. In terms of the high-risk subgroups we provided vaccine to 24% of that population. Through the efforts of the entire community vaccine was provided to 16% of the general population and greater numbers of the high-risk subgroups. We learned that it is a balancing act in public messaging to motivate the community to be vaccinated. We learned that the public demand was far less than expected. It is critical to obtain information early and distribute it as widely as possible. There needs to be close coordination between the local health authorities, the state and all private physicians. Federal guidance changed on a routine basis and we had to keep abreast of all changing information. Future challenges include vaccination of healthcare workers and use of PPE, expansion from high-risk groups to the entire population, the unknown level of immunity and susceptibility among the population, lack of funding for surveillance, media, uncertain funding for mass vaccination campaigns and outreach, mild flu seasons, suspicion of government, ability to reach high-risk populations, outreach strategies, balancing public messaging to get vaccinated without causing undue fear or alarm, and weighing the low public demand for vaccine being less than expected. Staff is working feverishly to determine how best to improve the vaccination rate for children aged 0-36 months. Our school-aged population has a high vaccination rate – it is those children not of school age where the numbers are low. Member Giunchigliani asked if school nurses can provide vaccines to younger children when the parents bring the school-aged children to school. Currently school nurses do not provide vaccines. Member Christensen said the focus needs to be on the 0-36 month age bracket; there needs to be a requirement for daycare entry for vaccine requirement similar to the school requirement to raise vaccination rates.


In closing, Dr. Middaugh noted that at the August meeting he mentioned that no 8010 funding was used to fund the public health informatics scientist’s position. In reality, a small portion of the salary is charged to 8010 due to an OMB Circular requirement, which states that if someone is funded by a specific grant that person can only work on that grant. As the incumbent is working on various grants, a portion of his salary must be charged to 8010 for compliance requirements. Safe Injection Practice Campaign Update In the interest of time, Dr. Sands asked that we schedule this update for another meeting.

VII. INFORMATIONAL ITEMS DULY NOTED

A. Chief Health Officer and Administration: 1. Monthly Activity Report, Mid-August 2010 – Mid-September 2010

a. Notice of Certificate of Achievement for Excellence in Financial Reporting from the Government of Finance Officers Association for the Comprehensive Annual Financial Report FY09

b. Note of Appreciation from Dr. James Lenhart to Dr. Lawrence Sands concerning “Healthline Today” Segments on Channel 3 Noon News Broadcast

2. Financial Data: Revenue and Expenditure Report for General Fund, Capital Reserve Fund and Public Health Laboratory Fund for the Month of August 2010 a. Grant and Agreement Tracking Report, as of September 13, 2010

3. Public Information Monthly Report, Mid-August 2010 – Mid-September 2010

B. Community Health: 1. Monthly Activity Report, August 2010

C. Environmental Health:

1. Monthly Activity Report, August 2010 a. Email of Appreciation from Randy Black concerning Whitnie Taylor, EHS II b. Email of Appreciation from Michelle Symonette concerning Candice Stirling, EHS II c. Email of Appreciation from Blake Feeney concerning Eduardo Rubic and Denise Young,

EHS II d. Letter of Appreciation from Victor Vincent concerning James Sladky, EHS II

D. Clinics and Nursing:

1. Monthly Activity Report, August 2010 a. In-service calendar

VII. ADJOURNMENT

There being no further business to come before the Board, Chair Strickland adjourned the meeting at 11:16 a.m.

SUBMITTED FOR BOARD APPROVAL ________________________________________ Lawrence Sands, DO, MPH, Chief Health Officer Executive Secretary /src attachments

M I N U T E Smedia.southernnevadahealthdistrict.org/download/boh10/...Staff: Scott Weiss; Angus MacEachern; John Middaugh; Glenn Savage; Jennifer Sizemore; Bonnie Sorenson; Stephanie

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