Senate Standing Committee on Business, Professions and Economic Development

Show of hands from the audience. Show of hands. Sorry to get everyone's attention. My staff and I were having a debate about this. Who has heard of Mario Day? Okay. I had not. I had not. And I've been notified that today is Mario Day, which is March 10th.

Mario, you learn something new every day, especially at the B&P Committee. So with that, thank you for that note. Welcome to this morning's sunset review oversight hearing, which is being held jointly by the Assembly Business and Professions Committee and the Senate Committee on Business, Professions, and Economic Development.

This is the first of several sunset hearings that will be taking place over the next few weeks, and I look forward to partnering with Senator Wahab, Chair Wahab in her new role as Chair of the Senate BPED Committee.

I would also like to welcome the Members who are new to the Assembly Business and Professions Committee and thank them for participating in this important oversight hearing. That's Assembly Members Addis and Hart. Thank you, Mr. Hart. Today we will be hearing from four entities responsible for overseeing the regulation of license, of licensed professionals in California.

The Board of Registered Nursing, the Physical Therapy Board, the Board of Chiropractic Examiners, and the Board of Barbering and Cosmetology. For each portion of today's hearing, we'll begin by hearing from representatives of the entity under review. Next, we will open the discussion up for questions or comments from Committee Members. Finally, we will invite... Good morning. Good morning.

Finally, we will invite other interested stakeholders here in the room to provide public comment. Speakers will be limited to a maximum of two minutes per organization. In the interest of time, additional speakers making substantially similar comments will be asked to simply provide their name and state their alignment with prior testimony.

I'm looking forward to a productive discussion today and would like to thank committee staff for both committees for all their hard work throughout this process. Before we begin, I will turn it to my Senate counterpart, Chair Wahab, for any introductory remarks.

Thank you, guys. So oversight is one of the more important functions of this Legislature. It's actually one that we should probably engage in a little bit more in my personal opinion. We do hear hundreds of bills every year that create new programs and tell government to do something.

Yet it is also very rare that we ask whether these agencies are actually functioning as they should. Many times, if you guys paid attention to our budget hearings, I have always talked about consolidation, duplicative services, a lot of bloat, and much more.

So these oversight hearings are incredibly crucial, particularly for licensing boards, which can hold the ticket to someone's livelihood. It is important that we evaluate whether they are efficient and effective.

I want to be clear at least my vision of this entire role is largely to make sure that we are protecting consumers, allowing more people to enter this particular workspace, depending on which board we are talking about. And I look forward to learning about the boards we're talking about today and this year.

Through this process, I'm especially interested in ensuring that we can provide opportunities for economic mobility to millions of licensees while ensuring access to quality care and service to the millions of California patients. So I look forward to this hearing and, again, thank you.

I second everything Chair Wahab said. Today's hearing will begin with representatives of the Board of Registered Nursing testifying today in the Board's is the Board's Executive Director, Loretta Melby, as well as Dolores Trujillo, Board President. Come on up. Ready whenever you are. By all means, thanks.

Good morning, Chairs and Members. My name is Dolores Trujillo and I currently serve as the President of the California Board of Registered Nursing. I am a registered nurse appointed by Governor Newsom to serve on the Board in a direct care provider role. I am joined today with Loretta Melby, the Board's Executive Officer.

Over the past four years, the Board has worked tirelessly to turn feedback from the last sunset review into measurable results. We heard your concerns and we acted. The Board has modernized licensing and education systems, streamlined enforcement processes, and significantly improved consumer satisfaction.

Processing timelines for every license type has been reduced, including a 31% decrease for RN exam applications and a 42% decrease for RN endorsement applications, allowing nurses to enter the workforce faster. Despite an increase in both the volume and complexity of cases, we have maintained stable disciplinary timeframes while strengthening complaint prioritization and probation monitoring to protect the public.

Despite an increase in both... Thank you. Annual enrollment in pre-licensure nursing programs increased by over 30% since our last sunset review. As we continue to advance in growing California's nursing workforce, an overhaul of the faculty approval process led us to being the first board in the nation to capture statewide data on the number of nursing faculty by specialty, area, and region.

Stakeholder engagement and education have been prioritized with the Board meeting consumers, licensees, educators, and employers where they are, ensuring that California's nursing regulatory framework is transparent and collaborative. Lastly, consumer satisfaction with the Board rose from 51% in 2022 to 70% in 2024, reflecting our ongoing commitment to listening and improving.

The lessons learned and the partnerships built over the last four years give us a strong foundation for the future. Looking ahead, the Board remains committed to advancing its mission while adapting to the evolving needs of the nursing profession. Loretta and I are happy to answer your questions.

Loretta will be addressing the operational and procedural matters and I will be here and available for any other policy issues related to our nine member board. Thank you for allowing us to speak today.

Thank you, President Trujillo. No, sorry. Gotcha. Any questions, comments from colleagues on the Committee? The Board of Registered Nursing. Madam Chair.

So the Nursing Board is one of the most crucial ones. We hear about nursing in pretty much all of our communities, especially now more than ever. You know, I kind of just wanted to understand what is the board's regulation limit for nurse practitioners to practice within one category of their certification? And aren't they still nurses at the end of the day? So with broad authority, depending on where they work?

Thank you. I'll be happy to answer that. So nurse practitioners are initially licensed as an RN first. That is accurate. So they could work as an RN. They are additionally licensed or certified in our state to work as an advanced practice RN, which is a nurse practitioner.

They have in California, they have an option currently to become licensed without a national certification. The national certification is required for any billing. So that is a CMS requirement, not a Board of Registered Nursing requirement. So when they do provide services, they do have to have a national certification.

We have a three tiered system in the state of California when it comes to whether or not the nurse practitioner has to have specific supervision or whether they can have independent practice. Upon licensure, they work under what's called a standardized procedure. That does require direct physician oversight.

Direct physician oversight does not mean they have to be physically present at the premises, but they do develop these standardized procedures. They're in accordance with the healthcare facility they're working within. Them as the practitioner and the physician. They work for that at a minimum of three years. Some choose to work in that role indefinitely.

If after three years they complete the transition of practice, they apply to our board. We advance their certification to what's commonly referred to as a 103 NP. That allows them to work without standardized procedures, again, in any specialty area that they want. It does not have to align with their national certification.

It is only when they move to a 104 nurse practitioner. That is an independent practicing nurse practitioner. That person must work with the way that the current law is written right now in alignment with their education, training, and national certification. So the national certification is done at a population foci level. So it is still broad. You can specialize within that.

So in my district, we have a lot of nurses. We have obviously a nursing school as well. And just for reference, East Bay, in the Bay Area. And one of the things that we constantly hear is that there's a lot of people that will go abroad to get their nursing education and much more.

What are we doing to kind of incentivize or create a bigger pathway for folks to get their degrees here, get their education here, and streamline it when they don't have to potentially jump through hoops, as we have a shortage?

Yeah. So when you say abroad, is that international, is that preparation international...

And pay a cheaper price for a full year of education versus, you know, our effort. There's also, and I do have concern about this, we have a lot of people from the international community who move here that have the qualifications, that have worked in hospitals abroad.

And we don't make it easier for them to get licensure here without going through everything or going into debt. So I just want to see like we talk about this for years, the public is frustrated with it, the lack of available nurses in rural areas and much more. We're just making it harder. What are we doing to kind of fix this?

So we've actually streamlined the licensing process exponentially. The example that uses the Philippines. They updated their memo and based on that memo, anybody that graduates from their BSN programs do qualify for licensure here in California. Prior to them updating their memo, they did not meet our licensing standards for the minimum qualifications on their education.

So once that memo was updated and they shared it out from the Philippines, the Ministry of Education, it aligned with our education requirements and preparations. And if you graduate from the Philippines, you should be able to obtain licensure fairly quickly.

What about Latin America?

Which areas in Latin America?

Name a country. Let's go South America, Central America, and then Mexico.

Typically there's no issues with them as well. So what happens is they come in, they fill out the application just like anybody does in the US or in California regardless of where you graduate from. Based on that application, they give us their transcripts.

If it's an international based transcript, it does go through a company typically called TruMerit. And that company translates the transcript for us. We do a review of the transcript. They meet our educational requirements. They either take the NCLEX If they haven't taken the NCLEX.

And the NCLEX is our national board exam that allows for anybody to be licensed in the United States to work as a nurse. And if they take that exam and pass it, they're licensed. There's not a different path in for anybody. Everybody is licensed under the same requirements. Whether it's California, US, or international, the requirements stay the same.

What's the timeline?

That is actually just improved. And so we do our first review within about two weeks. And most of the applications we do find out that are deficient, they're missing at least a transcript. Once that transcript is received. And we just recently partnered with Parchment and Clearinghouse, which are the two major transcript companies in the nation.

And then TruMerit is one of the international transcript companies that do that. And we partner with them as well. Based on receipt of that transcript, we process about two weeks after receipt of that transcript. But that's usually two weeks after we've reviewed it and said, oh, you failed to turn in an item. So if we get a complete application, it's processed within weeks.

Okay. And then are there any language barriers or, for example, if they are not a primary English speaking country, are there any requirements that you guys place or some mid level proficiency in English or anything like that?

We do. We do require a English proficiency exam if the education, if the school that you receive the education from was not taught in English. And that is because our National Council State Boards of Nursing, the company that administers the NCLEX, it's only written in English. So we want to make sure that they're successful in passing the exam. But that's the extent.

Okay. And final question, because I know I'm asking a lot. Your online programs. I've had the pleasure of talking to a number of online nursing schools, some of them that have concerns with clinical placements or having this. Have we talked about that? Because so many schools are going 100% online and I just kind of want to understand how you guys see that.

So we actually do not dictate whether they do online or ground. That is not something that's through the Board of Registered Nursing. We partner with the California Community College Chancellor's Office, the CSU's Chancellor's Office, as well as the Board of Bureau and Private Post Secondary Education, sorry, BPPE.

So they oversee the academic setting and they have their requirements. We only look at the nursing program. Within the nursing program of any academic institution, we look to make sure that that program will meet the licensing standards, be able to produce a safe practicing RN.

So we don't state whether or not it has to be online or in person. The one qualification that we do require is that of the 864 hours that they have to complete in clinicals, that they complete 500 of those in a direct patient care. Telehealth is also providing direct patient care, so a part of that can be counted towards that 500 hours.

Okay. And let's say they were online, they did telehealth, and you know, who knows what else. If they get a full time job eventually after they're licensed, is there, just for the online students, is there, you know, one to 2-3 month period where they are having additional training just because of the fact that they haven't had the true in person contact?

All of our new grads require some kind of additional training. They don't come out and hit the floor running. That is not something that is done. So each one of our healthcare organizations, which we just to be clear, we don't have any jurisdiction over them. They provide what's called new grad programs.

And those new grad programs vary from six weeks to a year depending on how they set them up and what specialty areas they're going into. And then with that, they determine what kind of support is needed because the hiring entity is the one that verifies competence before they actually go in and can provide the direct care.

Perfect. Well, I appreciate all of your work. I will say that I'm very much interested in making sure that we support the women, and it's largely a women's profession at this point, are able to do it even if they have children, if they have, you know, competing priorities.

And there's flexibility there as well as that threshold be simplified as best as possible for those that are trying to transition, let's say in their 20s, 30s, 40s, and are new arrivals to this country too. So that's my interest and, you know, hopefully you guys are paying attention to that. So thank you.

Yeah, nursing is fantastic for that. I'm actually a direct result of that. I was a PIC student and I had a 16 year old. I was 16 when I had my daughter and I was able to go and be here today because of this profession. Thank you.

Please, Mr. Vice Chair.

Yeah. Let me follow up on the international nursing program, and I want to get some clarification. If the nursing program internationally, if you are pre-approved and does that qualify for them to practice here or do you require their clinical experience? That number of hours that you require, it can be done in this country or do they have to complete that clinical experience in the country of origin?

So I think there was a couple questions so I'm going to try to answer both of those. The first question that I understood was if they have their training in another country, can they come straight in and work. They are held to the same licensing standards as everybody in California.

So if you meet the education requirements and you pass the NCLEX. And the NCLEX is a national recognized exam that all 50 states and four territories take, including two territories within Canada. They all have to take the NCLEX in order to...

That's a national exam.

It is a national exam. So they have to qualify to take that. That qualification is based on educational standards. We review the educational standards, we let the NCLEX, the people that deliver that test, know that they meet the standards, and then they still have to take that test. That is a United States requirement to be a nurse.

And so if we review your international program data and they meet the educational requirements that every nurse in the state of California is able to, is required to meet, then we say that they can meet that. There are occasions where we will note that they did not have the type of education that we require in California.

We will let them know that it's one course that they're missing. And if they can take that one course in any location that they choose to, again, as long as it meets that requirement. We work very closely with them. We actually have a designated international licensing unit that work specifically with the international applicants.

So clinical experience, number of hours are lacking, then you still require here for them to complete?

That is for everybody, whether it's US, California, or international. 500 hours in direct patient care is required for anybody, regardless of where they're educated.

Okay, the international students, once they pass the national examination, are they qualified for practicing right away in California or do you still require California board exam?

We do not have a separate exam here in California, no. So if you meet the national licensing exam, you're able to practice in California.

So regardless of where they come from, that's the first exam they need to pass before they can practice anywhere?

The first thing they have to do is they have to apply to some board of nursing in the United States. So we have 50 boards of nursing in four territories. And so they apply to one of those. One of those boards will review their academic preparation. And if that preparation meets, they let the national testing entity know that they can administer the exam. So it is two steps. They have to apply, education evaluated, and then they go and test.

Okay. Certain advanced nurse practitioners need to pass national examination. So that is a separate advanced exam than the basic exam that you are speaking about right now?

Correct. Every advanced practice licensed RN in the state of California is an RN first. They pass and must take and pass that NCLEX exam. So they have to take that licensing exam to be an RN first. Then each one of our advanced practice RNs, there's four distinct roles, have a national certification examination that they can take and pass.

Again, currently in California we only require that for one advanced practice RN, and that is the certified registered nurse anesthetist. There are three other advanced practice RN roles right now that are not required to have that national certification for licensure by our board.

That doesn't mean they don't have to have that exam, that licensure exam. They have to have that national board exam in order to bill for insurance. And so CMS requires them to have a national board certification in order to bill their patients for the services that they provide.

Now for them to be able to bill Medi-Cal or Medicare, that the national advanced exam licenses are required. Then is that up to the individual or do you require...

Sounds like that's more of an individual choice rather than the hiring institution requires for them to be able to bill directly to Medi-Cal or Medicare.

Some of the hiring institutions do have that in their credentialing process. Again, that's outside of the Board of Registered Nursing. We have a minimum licensing standard. We have asked in our sunset report to align with that requirement for all of our advanced practice RNs. What we want to ensure is that you don't license an individual who then can't practice in California because they're unable to bill or they're unable to get credentialed.

And so, if there is a length of time that passes from the completion of your nursing education, including your advanced practice education and taking that exam, the success rate for passing that exam exponentially drops. And so, by us allowing for licensure without holding them to that standard, we can be setting them up so that they're licensed but not able to practice.

I have a different area question. Certain advanced nurse practitioners are allowed-- certain categories allowed, to my understanding, to practice without the direct supervision of the physicians, particularly in rural areas. When they do that, have you run into any serious crises because of the lack of supervision, some unforeseen accidents that happen because of no supervision of the physician?

Not at this point, and I'll explain that a little bit broader. Right now in California, we have about 45,000 nurse practitioners in our state that are licensed here. Only about 3,000 of those nurse practitioners have advanced from working under that standardized procedure, direct physician oversight, to what's called a 103 NP.

That 103 NP is still not fully independent at that point. They are limited to the group settings that they're able to practice in, and one of the requirements with that group setting to be able to practice in requires them to work with at least one physician and surgeon.

So only 3,000 of our 45,000 nurse practitioners have even advanced to that level. In January of this year, we have had our first group of nurse practitioners of only those smaller group of 3,000 that have advanced to what's called the 104 NP, which is that independent practicing NP.

So we probably have less than about 100 nurse practitioners in the entire State of California that have just recently received their ability to have a full independent practice that is in line with their education, training, and national certification.

Those initial people getting those granting, which again is only about 100--maybe even less--that have received that could only start practicing in an independent manner as of last month. So we have not received any complaints, any concerns around this because they haven't begun practicing in that independent manner yet.

Okay. What are those particular areas that they can independently practice?

So we have eight categories that are at the national population foci, and so it's adult geri, pediatrics, neonatal, women's health, and psychiatric mental health. And then there's various, kind of-- whether they're primary care or acute care delineations between that, but that, again, is at the population foci.

So if you have a family nurse practitioner, you can work in the emergency room because that is a specialty of the family nurse practitioner. If you have a family nurse practitioner, you can also specialize in cardiac. And so, we don't regulate any of the specialty areas. We only license and regulate and oversee at the population foci.

So nurse anesthetists are still required to work under supervision of the physicians or are they allowed to practice on their own?

So nurse anesthetists are a little bit different, and so they're not the same as our nurse practitioners at all. So I'll explain what their practice is. The nurse anesthetist has a RN license, and then they also have an advanced practice certification. They're able to practice independently once the order for anesthesia is received.

So the physician and surgeon must say, I need anesthesia services, they then bring in the nurse anesthetist to deliver that, and in the operating room, the pre-operating room, getting them ready to go in, during the procedure and immediately following the procedure, they are able to operate in an independent manner.

Understanding that surgical suite, though, you are the nurse anesthetist at the head of the patient's bed, you have the physician in the room that is providing the operative services, and then you have--

They're still under supervision of the physician?

Not necessarily supervision. There is a physician and surgeon there that is doing the surgery. They do not have to supervisor the anesthesia-- the nurse anesthetist that is providing the ability for them to have the pain relief and the sedation and stuff that's needed to do the surgery.

They're focused only on taking care of the patient that is having-- like, they're cutting and doing everything that they do as a surgeon. They would not be able to supervise the nurse anesthetist at that same time. That would require an additional person.

And so that nurse anesthetist can select and administer all the medications, the oxygen, anything that is needed, any kind of emergency items that are needed to provide to that patient at that time independent of the physician and surgeon that's in the room. There is also additionally a surgical tech there and an RN that is there as well.

So even in this category of witness anesthesia, you haven't had any accidents by solo practicing?

Not typically, no, and nurse anesthetists have been practicing in this manner for greater than 40 years. And so, we do not see an increase or anything that has occurred around having them as an independent practitioner in California.

Thank you.

Thank you.

Thank you, Vice Chair Choi. So I have Assembly Members Hart and Pellerin, Senator Archuleta, and then anybody else who wants to get added to the list? Great.

Thank you, Mr. Chair. I had a question about Item Number 20. It's my understanding that there are thousands of California students who are doing online nursing out of state, the companies are headquartered out of state, and in fact, some of those students are in my own district and they have to leave California every semester to do their training physically out of state. And that-- I think that the online training is a great opportunity for folks who are stay-at-home parents or have family members that they're giving care to, variety of different things.

But it is a tremendous burden to have to relocate out of state every semester to do that training--understand the training is important--but shouldn't we be able to create some system in California that keeps California students here so that we can have them be in the pipeline to work in California institutions when they graduate?

Absolutely. We have a path in. It's called being board-approved nursing program, and any out-of-state entity that would like to be able to provide education to our California residents are able to become board-approved here in California. They have to go through the same review process as any California school.

We review them, we ensure that they meet the same standards, and as long as they meet the same standards, our board would consider all of their enrollments and all of their graduation metrics and attrition metrics and success measures the same as every other school here in California.

Do they have to have a physical presence in the school to do that?

The Board of Registered Nursing does not require that. However, if you're an out-of-state entity, they would be able to have to apply through the Bureau of Private Post-Secondary Education, which is a separate governmental agency. They do, at this point, have to have an on-ground location.

However, consistent with our in-state nursing programs, that could be within a strip mall. It could really just be an office building that is a kind of centralized hub, and we have many, many nursing programs in the State of California that require-- that have a setup within a strip mall.

Here in Sacramento County, we actually have two schools in one strip mall located right next to each other sharing a similar space, and so that space requirement does not tend to be a detriment.

So I guess it's really just the fact that a company like that that's operating nationally would have to go through 50 different licensure processes around the whole country, and I think that's a barrier. And in the meantime, the students here in California that are facing this reality, it's really a challenge for them, I think.

I can understand why you would see that on face value as being kind of a barrier, but I'd like to provide some additional education on that. So each one of our 50 states and four territories have different licensing requirements, different educational, different background, fingerprint requirements, et cetera. So they have various licensing requirements.

And federally, each school, no matter what program you come from, whether it's nursing, or IT, or anything, if it leads to a licensing exam or a licensing need in an individual state, you must prepare your curriculum to meet that. You won't know that unless you check in with each state to see what those licensing requirements are.

So that's really what is occurring. In our role with the Board of Registered Nursing, our focus is 100% consumer protection. When you have a student entering day one into an academic setting, they're committing to two to three years of their life to go to school, and they want to say that, if I start today, I'm going to graduate in three years and I'm going to be able to be licensed in three years. Because some schools are taking on upwards to $200,000 in tuition debt without a guaranteed outcome.

You can get a degree from a program and still not be licensed because you weren't prepared correctly. So the initial thing that our board approval does is verify the quality of that program, verify that their graduation rates are great, their attrition rates are fine, that their pass rate for the NCLEX licensing exam is there, because without passing that exam, you can't work as an RN.

So we at the California Board of Registered Nursing look at the metrics of the program. Then based on those metrics of the program, if they're not an at-risk school, if their quality indicators are met, they're able to grow.

The next thing that we look at is whether or not in that growth it would negatively affect a current approved nursing program. What we don't want to see--because we have a lot of clinical impaction; I'm sure you guys have heard about that, which is why some of those students are going out of state--is if you have 100 students in one area that are already enrolled in a program, already paying their tuition, and already planning to graduate in a year or two and you bring in another program that wants to do clinicals in that same space, because direct patient clinical hours, hands on, touching a patient is required, they could lose those, and then the students that are currently enrolled won't be able to progress and graduate.

So we require our schools to work collaboratively together to ensure that they have their clinical spaces, that they have faculty, that they have the resources in order to enroll day one and graduate at the end because what you don't want to have is generational debt.

What you don't want to have is a person that graduates and has $200,000 in tuition and no ability to get a job or no ability to pay that back. And so that's really where our consumer protection comes in. And so it does look kind of pretty simple, like, hey, just open up your borders, have everybody do clinicals. That is not the way that it actually works when you're boots on the ground and you're trying to manage and organize all of that. But there is a pathway in.

They just have to go through the approval process, make sure they meet our licensing requirements, allow us to oversee their metrics, and then make sure that they collaborate well with the current RN programs that are here in California.

And I appreciate that additional information. That helps a lot. And I guess the question then is, who is doing this coordination? Is it left to the business, to the nursing education program, to figure out these clinical placements? If they had a physical presence in the state, does the board help and assist that and make that work?

Imagine in a big state like California, as diverse as it is, it isn't consistently a problem everywhere; it's more acute in other places than others, and, you know, is that nuance factored in?

It is, and just to be blunt, it's almost consistently a problem in every location. So we are very much aware of that. We have a nine-member board, so this is our board president here, and all enrollment decisions, whether it's approval of our new program, growth of a current program, moving to a new location, is all reviewed by our nine-member board, and they look to make sure that kind of everything is equitable.

One of the things, when you say, what does a school have to do or a person that's not in school yet that wants to start a nursing program have to do, we have a very step-by-step outlined in regulation, a form that they can pull from our website. It's up there, it's there. They can go that-- they start off by submitting a letter.

It's actually written to me right now, the executive officer, but they submit a letter, and at submission of that letter, we assign a person on staff called a nursing education consultant. And so that nursing education consultant works side by side with them through the entire approval process, and then once they're approved, they continue to review them on a schedule to ensure that all the metrics continue to remain high and that the students and the community they serve continues to be happy with that.

And so they do have somebody that is assisting them through that entire process. When it goes to clinical placements, in our background paper, we have talked about a statewide nursing consortium that has regional focus. We don't have that currently, but that is something that would benefit us.

Yeah, I think it would benefit everybody--

Yes, it would.

--so thank you for highlighting that. Thank you.

Thank you.

Thank you, Assembly Member Hart. Assembly Member Pellerin.

Thank you so much for being here today. It's been very informative and I'm extremely grateful to our nurses. They provide incredible services in our communities. So I was just-- and I'm really grateful for this background paper too. It was very, very comprehensive.

So, understanding is that this is the only board that still requires that the executive officer be an actively licensed registered nurse, and my understanding is that other boards don't have that requirement. So I'm curious, is it necessary for the BRN executive officer to also be a licensed nurse?

I might be a little biased because I am that executive officer--

And you are, and so-- and I'm grateful for that. I'm just curious. I was just like--

I've been an RN for 25 years or longer, and our board president is an RN right now, so we might be slightly biased. We are the only board in the State of California that requires RN licensure. However, equal to most the boards in the nation, it is a requirement to have an RN in the executive officer role. It's not that you have an RN and you can be an EO, right?

So in order to be an executive officer, you still have to possess that minimum skill set of administrative, having that experience, having that work ethic. You still have to have that. It's the additional layer that we also want to have the licensee because there is some nuanced things that come up frequently, that unless you're an RN, you may not have a full understanding of that. That was really kind of ran home with me.

I started in this executive officer role in an acting position on February 20, 2020, just two weeks before the world shut down, and I truly believe that because I had an extensive nursing background, that that truly allowed me to jump in and really lead the board through-- and the largest amount of nurses in the entire nation through that extreme kind of disaster that came right in front of us.

So being able to take in my knowledge of working as an RN at the bedside as well as working in nursing programs--I was a prior nursing program director and faculty--and so I was able to understand all of those distinct roles and how they all must play together in order for us to come out and be successful in this.

And so having that extensive background education and nursing knowledge, I think, really, truly did allow for us to move through this a lot faster and better than if we did not have that.

Thank you.

Thank you.

Thank you, Mr. Chair. Thank you, first responders. You know, we all love you. There's no doubt. Those of us in law enforcement, firefighters, everyone--we just love you. As a veteran, as chair of the Military and Veterans Committee here, my concern is the men and women who were medics in all branches of service, intensive battlefield experience, and so on, and then they come out and they're trying to get licensed or get-- walk me through a process that would reward and acknowledge these veterans who've given so much to our country.

So there's a couple ways to become licensed. So if you're already licensed as an RN in another state and you're here on military orders, or your partner or spouse is here with you and they are an RN licensed in another country--in another state, sorry--they just go on a listing here. There's no licensing requirement in California.

They can just come right in, be part of that listing, and work as long as they're here doing their duty. If they're in a federal agency, again, no license required in California. They can work in that federal hospital area without having a California license.

If they have military preparation and they haven't sat for that national licensing exam that, again, is required throughout the United States in order to take patients, they have to meet that qualification. That qualification is based on experiential credit to meet the educational standards. So the educational standards are still the ones that have to be met.

Our staff are not specialized in that, so what they do is any military personnel that has their military transcripts or their experiential credit will bring it to a board-approved program in the State of California, have that program evaluated for licensing requirements or degree granting requirements, and if there is anything that is lacking in their preparation specifically--they probably aren't birthing babies out on the field and that's something that is part of our general licensing requirement--they may need to take some additional obstetrics or women's health kind of stuff.

And then once they receive that, that school grants them their licensing completion--education requirements for licensing completion, sorry--and then we treat them the same as everybody else at that point.

Good. Thank you. We also talked about the Philippines and people coming in. You know, but that tells me that, what about our schools? Does the board work with our local schools, universities, to try and enhance the classrooms, involvement, recruitment, so we don't have to look at other countries? Because there is a dire need for our nurses.

So what are we doing as a board to help our medical students that want to go ahead and practice and be involved in nursing and get involved in school so they can? What are we doing to kind of bridge that gap that sounds like it's missing?

So each one of our nursing programs in the State of California are assigned a nursing education consultant. That is a board staff. That is a person who is an RN with at least a master's degree in nursing that has extensive education, regulatory knowledge, and they help them get approved and help them become a institution of higher education for all of our nurses to be able to successfully graduate them into the nursing pipeline.

So every single school has an assigned nursing education consultant. So they probably have a ratio about a 1 to 20, 1 to 30 at our peak, but they are able to email them directly, call them directly. They actually email and call me directly, and then I get on Teams, meeting with them extensively. I go to various different areas and present to their staff, to their students, et cetera. So we all-- we work very, very closely with all of our approved nursing programs.

And one suggestion would be to start working with the high schools, community colleges. Get some of your board members and staff to visit these schools and get these young men and women interested in nursing. That would help deviate from what we're hearing about recruiting outside that we could do it inside.

Yeah, and we actually do that as well. So our community colleges, all of their nursing programs are with us as well, and we work with them extensively. And then, I have done two speaking engagements just last year at local high schools--

--to encourage them to come in.

Good.

Thank you for your service.

Thank you.

Thank you.

Thank you, Senator. So I have Assembly Members Caloza and Addis, and then anybody else? Not yet. Okay.

Thank you so much, Chair Berman. Thanks for your presentation today. I represent District 52, which is Northeast LA, South Glendale, East LA. I have six hospitals in my district, including the only children's hospital in Los Angeles, and collectively, they employ about 5,500 nurses.

I also come from a family of nurses and I'm also Filipino, Senator Archuleta. So very familiar with the nursing field, but I guess for me, I wanted to ask big picture. I know that-- thank you, one, for your work and your leadership leading us through the Covid crisis.

What are you seeing now as it relates to kind of the nursing profession? Is there a shortage that we should be working to address, is one question, and then the second question is also, when I meet with constituents, students specifically, I know that the pre-nursing programs and nursing programs are some of the most competitive to get into, and what are we doing to address that?

So I'm going to actually pass this over to my board president just to address the work shortage stuff. She's a currently working RN right now, does NICU at nights, and so she's right there with it.

Thank you, Lori. Thank you for that question. We have approximately 500,000 nurses licensed in this state. Not all of them are working as nurses. Probably about 20% of them do not work as a nurse, even though they have an active RN license.

While some of this loss can be attributed to retirements, there are many RNs who report that they left the workforce for preventable reasons, including job-related stress and burnout, lack of support from supervisors or employers, lack of work-life balance--work as a nurse can be emotionally challenging--lack of a positive culture to work in, and the lack of retirement and pensions and other benefits.

So the shortage in our state, while part of it is a pipeline issue, getting nurses in, we have schools that are graduating new grads, and these new grads are now trying to get jobs and pay off their student loans, and a lot of them are not able to do that.

A lot of them are having to go out of state to get this experience as an RN because many hospitals have done away with their new-grad training programs and they're hiring nurses with experience, right, because it's cheaper. And so they're hiring nurses with, let's say, a minimum of two years. It's very rarely one year.

It's usually two years and up. So these new grads now with the burden of having to pay back these student loans are going out of state to gain that experience and then hopefully come back into the state to obtain employment and work and bring their families back in.

So I feel like a lot of this problem is employment of our new grads. We need to get our new grads into the pipeline of California, and I think it would not solve the whole shortage through that pipeline but it would go far to mitigate some of the issues that we have in hiring nurses.

Now, we have pockets of surplus nurses in certain areas, say Southern California, and then our rural areas have a shortage. So I think also by hiring these new grads into some of those rural areas, giving them the incentive that they will be trained to function as RNs in those areas, would help mitigate the shortage in these rural areas.

Yeah. So just to add some additional information on that, so we have a pretty robust pipeline in California. We graduate-- out of, I think, the nation, we are one of the top three producers of nurses academically, and so with that, we have a stable pipeline. We're continuing to grow that pipeline.

We're continuing to re-- we've approved new schools, we approve new campuses, enrollment growth. That's in our background paper as well, so thousands of new nursing students every year added to the pipeline. Really, that focus is, once they've graduated and completed and met licensing standards, how do you keep them here in California so that you don't have them taking travel positions out of state or leaving the profession completely?

And some of that comes through what we have authority over where we look and approve all of our California schools. Based on that, we review curriculum, we review faculty requirements, we do all of that to make sure that we're assisting that program to meet all those minimum standards and be able to support them when they're fresh and new and out there so that they don't run away.

The largest exodus of RNs is within the first two years from licensure. They decide not to leave the job but leave the profession because they don't feel supported and there's a little bit of a shock once they go from academic preparation to in-person working.

Thank you for sharing that, and, you know, I would love to work with you on that to see how I can better support, from my family's own lived experience in the profession, but something I know I'm deeply concerned about, and how do we make sure we retain the nurses that we're working really hard to train and license in California and how do we keep them in this profession? But thank you both for your work, and I'll follow up with you after.

Thank you.

Thank you.

Thank you, Assembly Member Caloza. Assembly Member Addis.

Thank you. Thank you so much, Chair, and thanks to both of you for presenting. I, too, am the daughter of a nurse and have heard many of these stories around the dinner table, particularly why people stay and why people go, and my questions were similar to Assembly Member Caloza's, but maybe a little bit more around data.

So we hear the stories around there being pockets of surplus and pockets of shortage. My area, certainly, we have what we call a healthcare desert on the Central Coast and have done a lot of work to build up the allied professionals, physicians, nurses, and others in the healthcare field.

But for some healthcare professions, there's data that shows that they actually do stay where they've gone to school, and I'm just wondering about the data for nursing school, if that data exists or if it's more anecdotal. I did hear you say we have a stable pipeline.

We have a lot of growth in terms of the number of schools but that there are people leaving the state at the same time that we're bringing in nurses from other states as well as internationally to serve in California. But what does the data say around people staying where they went to school, and then what else can we do? Which is similar to what you just answered, I realize.

That's okay. Thank you for asking the question. I work closely with HCAI, and so they are responsible governmental agency for really tracking a lot of our healthcare data, both growth and recession. And where is that at? I can give you a copy of this map. This is actually our map that is used to predict no shortage, low shortage, medium, high, or severe shortage.

And they take into consideration nursing migration, so where they went to school and where they work and where they live, and those might be different locations. So we watch all of that. I work very closely with them and we monitor that.

And so based on that, we do have a lot of really great reliable data that where they go to school is where they end up typically working. What we need to do better at is really recruiting into those rural areas or the areas that do not have a high nursing population at this point.

And so, one of the kind of catch-22s that happen with that is they don't have the clinical spaces in those areas because they don't have a fully licensed hospital. They might have an emergency access hospital. They might have emergency access hospital like some in-- like Bishop and Mammoth and stuff like that where it-- their census or their patient population increases during the winter when there's a lot of people there, but there's nobody there in the summer.

And so taking all of that stuff into consideration in order to get appropriate clinical preparation, because the one thing is, even in those rural areas, if you want to have students there, they need to be prepared because they're going to be working in a very unsupported fashion, because, again, they don't have the providers in that area and you might be the only nurse on two or three different floors in that hospital, and that's a very difficult thing to step into as a new grad.

And so, in those areas, you really want to make sure that that training stays robust and that you continue to produce qualified licensees in that area. You don't want to decrease any of the educational standards. So we work closely-- I meet with schools that are out of state.

There is a school in Nevada and a school in Arizona right now that are currently going through our approval process because they want to become a school, a board-approved program in California so that they can have some of their students that might be there in Reno to go across to Susanville or Lone Pine or anything in those areas to be able to provide clinicals as well as provide any kind of nursing services in there.

So we have that pathway, we look at that all the time, that is something we're very much aware of, and we continue to encourage schools because you might have to have a ground location in California based on BPPE, but you don't have to be located in that area.

So that's the thing, is you can have a campus in LA, but you can provide online coursework and direct patient care in Big Pine, in Lone Pine, in any of those areas. You don't have to be physically present, and so, by allowing that flexibility to capture that online student is really a benefit to meet those needs.

Thank you.

Thank you. Assemblymember Addis, any additional questions or comments from colleagues? Senator.

Good morning. Thank you. I was looking at some of the amazing data. You all are one of the boards that collect a lot of workforce data and I know my colleague just asked about some of the indicators from that data.

One of the things I'm curious about is sort of the mobility within the nursing profession, particularly the LVN to RN steps. I'm also the daughter of a nurse. My mother was an LVN who became an rn. And at the time there were so many programs that were available and accessible and really fast tracked programs.

So I'm curious about the 30 unit optional program. If you could give us a little bit of an update on, you know, are LVNs acquiring a license through that pathway?

Is it appropriate in terms of the amount of training that folks are getting, but also the efficiency in which they're able to transition into a higher pay, higher skilled classification?

And then my last question is, you know, I represent South Central Los Angeles and unfortunately we are also in a healthcare desert, particularly where it comes to maternal health. We are critically short of diverse workforce that really has the cultural competency to support our communities.

We, we have a large, the largest, highest density of black women in my district in the state. We also have, you know, we're a gateway community. So we have a lot of newly arrived families, both from, from Central America, but also from East Africa, a lot of French speakers and so forth.

So I'm curious about the upward mobility for, for nurses, particularly from the LVN to rn. And I'm also curious about what is our data showing us in terms of the diversity of the workforce overall and particularly those underrepresented populations that exist, particularly black nurses and nurses that are able or multilingual and able to serve BAS communities.

There's a lot to unpack there. Thank you. So I'm going to try to remember it. I might have to ask you to repeat if I didn't get everything there.

So when you're looking at the diverse pipeline that is typically seen with our community colleges, our community colleges serve the community that's around them and they have specific enrollment requirements that are met and we work with them on growing them and doing that. Recently, our private colleges and universities are also saying, hey, we'll take anybody in.

We're going to help them. We're going to help them be successful. That's really our focus at the Board of Registered Nursing is not where you go to school, but that the school that you do go to gives you what they say they're going to do, that's that consumer protection.

And so we really want to grow the schools in the areas that need that. We also want to ensure that they have the support. When you come from a impacted area where they don't have the same access to everybody, getting to clinicals and from clinicals is very difficult. Right. So not everybody has transportation.

So when you have a school that's growing beyond their means and they've got a clinical location that's 50 miles away, how do you get your student to that clinical location? That becomes problematic as well.

And so really working through the various support systems, looking at what is occurring and how we can better support them, we have had on occasion where people say, well, the student, this, this and this. And our board routinely flips it back and say, well, no, you enrolled that student.

So if you're saying that this student is consistently not prepared or not successful, what are you doing to support them? And so that's really another avenue that we have for just getting anybody in that is interested in this.

One of the other things when you're looking at getting a diverse nursing population is all of the entries practice, how does this happen? We are the only state in the nation that does not require a nursing degree in order to become licensed in California.

Every other state requires at minimum an associate degree that is not obtainable by all. And so as long as we have licensing requirements that are met, we are able to offer apprenticeships, we are able to offer any kind of these pathways in over on this side of the room, there was a talk of military.

That is the same kind of situation that we do with our LVNs. And so we have many LVNs that want to go back to be RNs. We have our generic path, which means it's exactly the same as anybody that enters off the street. They just walk in. You have zero education.

We're going to start you at the beginning and carry you all the way through. If you're an lvn, if you're emt, if you're a paramedic, if you have a medic background as part of the military services, they do an evaluation and see where you land within the program.

And they are required through our regulatory process that they give credit to where that person is. So they do. They can get partial credit even for part of a program or part of a course, they have to get that done. So they look at experiential credit, they look at transfer credit, they look at CLEP credit.

Then additionally, is that 30 unit option. Now, each one of our board approved nursing programs are required to give the credit for anything that's there. They are also required to offer the 30 unit option as part of every nursing program.

So we have about 163 nursing programs in the state of California with well over 30,000 nursing students in every single one of them, they have to have this option in addition to that option being offered. They do have to give them some counseling around that.

Because the 30 unit option does not lead to a degree, it is a certificate. The 30 unit option only allows them to sit for that licensing exam. It makes them eligible to sit for that nclex.

What that means is because we are the only state that doesn't require a degree for licensure, they typically are not able to get licensed in another state if they complete that program here. However, we know the vastness of California.

So if that student is staying in California and wants to be a nurse in California and they're an lvn, that is a viable pathway for them. It is that the school cannot require more than 30 units of semester units. So that is where we hold them to is they must be educated in as few as 30 units.

They cannot go over that. There are specific requirements where they have to take some specific coursework so that everybody is prepared. When I was a nursing program Director, I had three students take that pathway. Only one of them successfully completed the pathway and gained licensure. However, she was amazing.

She was an LVN and now she's a critical care transport nurse flying around in helicopters doing amazing things. So there is that option there. It is not taken routinely, but it does open that pathway up to apprenticeships and really recruiting in and making that non traditional student something that the nursing pipeline can support.

Did I answer all of your questions? I'm so sorry.

No, you, you did a great. You did a fair job of getting to most of the issues. So in terms of the. And maybe I'm appreciating understanding the pathway and how folks get there. I guess I'm.

I'm also curious how many percentage wise, I don't know if we have this data of LVNs do take either the 30 unit path or they go through a non traditional. Who. How many are transitioning and moving up in the profession? That's. And then I think you sort of answered the question about the diversity of the workforce.

And I'm hoping to get more of a sense of what does our nursing field look like demographically and particularly when we look at underserved communities.

So Yeah, A little more global on the demographics and then a little more specific in terms of the upward mobility of LVNs into the RN status we have on our website and if you want me to, I can pull it up.

We have all the demographic data for every of our all of our pre licensure nursing programs. Those are all kept on our website. And it does show that we actually do a pretty amazing job with the diversity. We're not there yet. There is more that needs to be done. We need more males in nursing.

We actually need more African American in nursing. 100% across the board. When nursing was kind of brought forward, they wanted bachelors of nursing to be an entry level requirement. When you require a bachelor's of nursing as an entry level requirement, you're not going to get the diverse population. I shared earlier that I was a teen parent.

I had my daughter when I was 16. I did not get a bachelor's degree starting I came in and got an associate degree. I did it an accelerated program while I had my job so I could support my daughter. I then went back and got my bachelor's and then while I had my bachelor's continuing to work.

I then went back and got my master's and now I was able to be here. I wouldn't have been able to do that if I didn't have a pathway into nursing that was non traditional. I was not the traditional student and could not be that traditional student. So having the no degree requirement in California is key.

That is key to having a diverse nursing population. I also work at the national level, so I work with National Council, state boards of nursing. We work with the United nations, with the World Health Organization and the birth rate in the world is not enough to sustain the amount of nurses that we will need in the future.

So that becomes an issue. So what you have to do is not rely on kids coming From K through 12 to go into nursing. You want that, but you don't want to rely on that is how do you attract other professionals into healthcare. Healthcare is the second largest profession in our nation.

Second to it computerized kind of specialties. So knowing that health care is the second largest employment opportunities in the nation and being mostly female, how do you support that?

So supporting them so they don't leave, getting the pathways in that are not a strict requirement and making it accessible through apprenticeships, being able to work while you go to school is key. I couldn't have done it if I wasn't working.

We'd have been homeless and in La actually they have at ELAC East LA College, they have a parking lot that they allow their nursing students to park and live right next to the school because many of them are homeless that go to that school.

But LA City College tends to have an amazing success and pass rate because they have the support services in place. So there's so many different avenues that need to be addressed to be able to support the non traditional student, to get a more diverse background, diverse workforce. Apologize for that.

But currently nursing tends to do a really good job at that. I could pull it up and read off of it to you or I can send it to you afterwards.

Yeah, please do send it to the office after. And I would like to get drilled down a little bit more on the pathways. We have an amazing network of K through 12, some magnet schools that do a lot of health and science, stem and we have a tremendous number of community colleges.

I have West La, which is a biology and health campus that is also significantly black in terms of student population. So I think it's the question of how do you build the right partnerships and pathways that folks know that the field is for them and and that they have an entry point that's accessible in their community.

So I'm happy to work with you on that and look forward to seeing that data so that we can follow up on this conversation. Thank you.

Thank you. Senator Smallwood-Cuevas. Any additional questions or comments from colleagues? I know we've got a lot of folks in the audience who probably have comments to make before they do.

I just, rather than asking any questions first, thanks to colleagues for the breadth of questions that were asked and thanks to the presenters for the depth and thoroughness of your answers. And I just want to give my personal thanks to all the nurses out there.

A lot of folks know that my wife and I had our first baby last year and without diving into a lot of the details, it didn't go as smoothly as we'd hoped. And my wife had to be separated from our baby for a lot of the first 24 hours after he was born.

And the nurses at the hospital and they got creative and really bent over backwards to help my wife just get an hour with our baby during those first 24 hours. And I can easily say that that was the only bright spot of those first 24 hours was that time together that they had.

That was solely due to the nurses and they're just doing everything they possibly could to bring them together. So such appreciation. We had a chance to go back and thank them and bring them some goodies. And then they so appreciated our thanks.

And so as also a reminder of go thank the medical professionals that help you out because they don't get enough thanks. And we should really do everything that we can to show them the love that they show to us in our times of need. So thanks to all the nurses out there. Thank you both for your presentations.

Thank you. And we're going to open it up to interested stakeholders here in the room to provide public comment. Speakers will be limited to a maximum of two minutes per organization. In the interest of time. If anybody before you says what you want to say, go ahead and just say plus one. We're going to have the.

There's a microphone right back there, I think. Yep. We're just going to stick with that mic to keep it simple. And two minutes. I apologize, y'all. I'm going to have to be a little bit tough on, on keeping you to two minutes. So it's not personal.

But if you can keep your remarks at two minutes at most, that'd be great. Go ahead.

I was prepared to sit next to Laurie, so good morning Chairs Wahab and Berman. My name is Sarani Hayre-Kwan and I'm a family nurse practitioner in the beautiful state of California and I'm here on behalf of CANP, the California Association for Nurse Practitioners. CANP is here in support of the continuation of the BRN Sunset.

The BRN plays an important role in overseeing our profession and fulfilling its consumer protection mandate. CANP has provided extensive comments to the Committee about the policy changes you are considering from the perspective of nurse practitioners.

We would ask that the Committee focus on clarifying Assembly Bill 890, the landmark legislation passed by this Legislature in 2020 with Dr. Jim Wood that allowed specified nurse practitioners to work without physician supervision. It was a very complex piece of law and we have continued to work with the Board of Nursing on its full implementation.

Yet we are still not there. We asked the Committee to amend the sunset bill to address these outstanding issues as well as all of the other nurse practitioner issues highlighted in our letter.

Thank you for your work on behalf of nursing profession and CNP looks forward to working with you as a partner and a resource through this process. Thank you.

Thank you very much.

Good morning. I'm Roxanne Gould representing the Association of Clinical Nurse Specialists. They are highly educated master's, doctoral or postgraduate certificate level education. I'm here for two different reasons. One is to try to request full scope of practice. Currently they wouldn't be authorized to prescribe vitamins.

They wouldn't be authorized if Someone chokes, they wouldn't be authorized to assess the swallowing capability of a patient. If a doctor says a patient needs crutches but forgets to order the crutches, they aren't authorized to order crutches despite this amazing education that they have.

And so we're hoping to advance the ability and allow them to practice to the full scope of their education. The second issue is that the Federal Government has limited the number of certificates, certifications that they authorize. And there are only three. And I have them listed when you would know them, obviously, but there are only three.

And what that will do is completely eviscerate the number of clinical nurse specialists that can practice in the state if they aren't in those three particular categories.

And so we're hoping to find another avenue, working with the board to figure out what other educational avenues there are, what kind of training, some other way to allow those clinical nurse specialists to continue to offer the vital services that they do. This is particularly important in rural areas as well. So thank you for the time.

Thank you very much.

Good morning Chair and Members. Jason Bryant, on behalf of the California Society of Anesthesiologists, appreciate the Board in its efforts to clarify CRNA practice, particularly in light of last year's legislation AB 876. And we do want to flag however and note the Board's proposal on issue number 13 regarding APRN delegation authority to our ends.

We respectfully urge the Committee to ensure that any statutory changes arising from this review preserve that physician direction via order and support safe collaborative team based Anesthesia care. And we look forward to working with the Committee on these issues and appreciate the time. Thank you.

Thank you.

Good morning. Chris Kahn representing Nightingale College. We're a hundred percent online nursing school located outside of the state of California. We appreciate the conversation on the online model. We have 7,000 California students who currently, currently have to do their clinical work outside the state of California.

Forty percent of those, Senator Smallwood-Cuevas, are LVNs trying to become an RN. It's a huge hardship for these students to have to do this out of state. The pathway that's in place now to become a registered school doesn't work for the online model. We would have to do that in 50 states.

Having the physical presence in California would hurt our designation at the federal level as a distance learning school. So we're hoping that this process, we can develop a pathway that can work for those students and take away that hardship and let them do the clinicals in California, become nurses in California and stay in California. Thank you.

Thank you.

Good morning. My name is Divya Shiv and I'm with the California Alliance of Child and Family Services which represents over 200 community based organizations that serve children, youth and families throughout the state.

All of our CBOs struggle with the behavioral health workforce shortage and the 103 and 104 nurse practitioners is one critical path for our Members to address this shortage.

However, many of these nurse practitioners have difficulty in attaining the 103 and 104 licensures that enables them to practice with greater autonomy and this is despite the fact that these nurse practitioners are taking on senior leadership roles within these organizations.

Specifically, many nurse practitioners struggle to accrue the 4600 clinical hours required of the 103 licensure as many of them use some of their work hours to engage in administrative duties and organizations also report difficulties around limited administrative support to track hours in compliance, lack of structured guidance on completing the transition to practice requirements, and limited organizational education around AB890.

Organizations also struggle with the ability to hire full time psychiatric mental health nurse practitioners because these organizations do not have psychiatrists that can do not have enough psychiatrists to provide the supervision required.

We thank you so much for this sunset review and we look forward to working with you to address these challenges that our members nurse practitioners experience in attaining the 103 and 104 licensures. Thank you.

Thank you.

Good morning Chair and Members. George Soares with the California Medical Association. Appreciate the presentation this morning and everyone's time. Just wanted to highlight a few issues. Issue number seven out of State related to out of state nurse practitioners.

We have concerns with this issue relating to nurse practitioners from out of state having authorization to practice independently in California without fulfilling the state's transition to practice requirements. CMA opposed the provision SB 1451 that was referenced in the analysis in 2024 that would have made the similar change.

California should maintain the requirement for an in state transition to practice. Issue number nine related to specialty delegation. We have concerns about moving away from the BRN's current approach of tying nurse practitioner practice to their national certification and a population focus issue number 12 related to ratios.

We're monitoring this issue to thoroughly understand the impacts to physician practices as it relates to nurse practitioners to physician ratio. Issue number 13 was mentioned by my colleague from CSA. We align our comments there. And just as a reminder, this Bill or this provision was removed from a Bill last year on that topic.

And lastly, issue number 16 related to data collection. We believe it is beneficial to have an accurate snapshot of where advanced practice nurses and all provider types are practicing. In this case, they are practicing in a particular area of specialization for nurse practitioners. We believe that it is different than population foci designation.

This helps to better inform us about healthcare access in California and is particularly important for access in underserved areas. Thank you, thank you.

And thank you for aligning your comments with the prior speaker when that's relevant.

Good morning Chair and Members. Jen Chase on behalf of the University of California, UC contributes to the nursing workforce through our four schools of Nursing and by providing thousands of clinical placements for nursing students from CSU community colleges in private school programs at our UC Academic Medical centers.

So the CSU, the UC along with the CSU, AICCU and California association of Nurses submitted a joint letter, so I was just going to briefly mention one of our concerns. Overall, we're very deeply invested in ensuring that the BRN oversight supports high quality nursing education, workforce development and patient safety.

But one thing we would like to consider as the Board moves forward for the review is that the Board review and align its standards, data requests and documentation requirements with those already accepted by nationally accredited, nationally recognized accrediting body.

Currently, the BRN requires extensive documentation that is duplicative and in addition to the extensive information our programs already report through the accreditation process. These additional requirements are extremely time intensive and resource intensive. So we encourage the BRN to review its current accreditation standards and provide clear justification for acquiring any additional data elements.

Thank you and we look forward to community engagement on the sunset process.

Thank you very much.

Good morning Chairs Wahab and Berman and Members of the Committees. I'm Evangeline Fangan Gagalang and I serve as the Associate Dean of the Colleges of Nursing and Health and Health Sciences at Azusa Pacific University. And I'm also the President of the California Association of Colleges of Nursing, representing over 60 colleges and universities across the state of California.

Thank you again for the opportunity to offer brief remarks and thank you to the VRN for their continued work. We join our colleagues from the UC and CSU in making four key considerations as written in our letter.

I'd like to focus on the continued need for clarification and consistency among nurse education consultants as it pertains to the role in faculty hiring processes as outlined in existing statute.

As President of the California association of Colleges of Nursing and serving in an Associate Dean's position, I hear many of my nurse educator colleagues continue to voice concern about their BRN Nurse Education Consultant, requiring them to fill out forms to provide faculty eligibility to teach BRN regulated courses.

So those are courses like Pediatrics, Med, Surg, Psych, Mental Health, Obstetrics and Geriatrics. Many of us know that this rule is now obsolete, at least for nursing programs that have national accreditation such as ours. Our understanding of existing laws that if a program is nationally accredited, forms such as the EDP PO2 are no longer needed.

But we find that because the BRN's website is not fully functional, program directors or designees still must fill out these forms. These forms take a lot of time to complete. It is unnecessary and time consuming, and it is taking us away from what we need to do, which is teach our students and administer our programs.

We ask the BRN to follow the current statute as it is written and stopped requiring program directors to submit the EDP PO2. Thank you again for the opportunity to provide this input as part of this process. Thank you.

Thank you very much.

Good morning, Chair and Members. Alex Graves with the AICCU, representing roughly two dozen private nonprofit colleges offering nursing programs in the state. Thank you for this hearing and thank you to the BRN for the important work you do.

As mentioned by my colleague from the UC, we submitted joint comments along with UC, CSU and the California State Association of Colleges of Nursing outlining four recommendations. One of those that I just like to highlight is there's been a lot of discussion today around placements and the need to address that.

One thing we would like to put forward is a consideration for modernizing the placement language for what qualifies as a healthcare or medical setting.

If we can expand the placements, environment and locations that we have, we can have more students doing placements, which means we can then have more students coming into all of our programs, across all of our institutions for those placements, which helps ensure there's more opportunity for people who want to go into the profession.

But then importantly, there's more people coming through with those degrees going into the profession. Thank you for the consideration.

Thank you. Thank you very much. Next.

Good morning.

Thank you, Chair, Members of the Committee, Chris Morales, on behalf of the California State University Office of the Chancellor, in alignment with my colleagues from the other higher education segments, one of the most significant challenges facing nursing education and one that is increasingly bottlenecking our ability to meet today's workforce needs, is securing high quality clinical placements for students, particularly for Master of Science in Nursing and Doctor of Nursing Practice programs.

These programs require hundreds of hours of supervised hands on training with qualified preceptors in real health care settings. Given the already limited availability of clinical sites for this type of training, securing these placements is increasingly difficult. This challenge has become even more complex as out of state nursing programs increasingly seek clinical placements within California.

In many ways, this creates a two track system where out of state programs educating students within California are not held to the same standard as in state nursing programs. Currently, California based nursing programs must undergo a rigorous process and approval through the brn.

The CSU, along with other in state programs, invest significant time and resources to meet these standards because they are essential to maintaining high quality education and and protecting patient care. However, many out of state programs are able to place students in California clinical sites without undergoing the same approval and oversight processes.

At the same time, the growing practice of paying for nurse practitioner preceptorships is further distorting the clinical placement landscape and making it even more difficult for California programs to secure placements. As the Committee considers the Sunset Review, the CSU urges consideration of regulatory parity between in state and out of state programs.

Doing so will help ensure a level playing field, protect the integrity of clinical education, and support the preparation of the nursing workforce. Thank you for your time and consideration.

Thank you. Name and Affiliation Please

Good morning. My name is Kristen Roman and I have the honor of serving as the President of the California Association of Nurse Anesthesiology. Today. I'm speaking on behalf of more than 2,800 certified registered nurse Anesthetists and Nurse Anesthesia residents across California.

Ken is pleased to express our strong support for the California board of registered nursing's 2026 Sunset Review Report as it's currently written. We appreciate the Board's thoughtful work, transparency and meaningful stakeholder engagement throughout this process.

I want to thank the Chairs, Senator Wahab and Assembly Member Berman, and the Members of the Senate Business, Professions and Economic Development Committee and the Assembly Business and Professions Committee for your continued engagement and diligence in conducting the BRN Sunset Review.

This process is vital in supporting the regulatory framework that keeps pace with modern nursing practice and supports a workforce that can meet the needs of patients across our state. We would like to specifically highlight Canna's strong support for issue 13 regarding APRN to RN delegation.

This provision clarifies existing practice and provides explicit statutory authority recognizing how care is delivered today in hospitals and facilities everywhere. As noted in the Sunset Review Report, the ability for APRNs to direct registered nurses is critical from both an operational and an access to care standpoint, and CANNA strongly agrees.

Across hospitals, ambulatory surgery centers, rural facilities, and community based settings, APRNs serve as clinical leaders coordinating care, overseeing nursing teams and ensuring appropriate delegation consistent with their education and licensure. Clarifying this authority promotes regulatory certainty, strengthens team based care, and helps preserve timely patient access to services.

At a time when California continues to face workforce shortages and increasing demand for care, clear and modern statutory language is essential in maintaining efficiency while upholding patient safety.

We respectfully urge your support for the statutory language recommended in the BRN Sunset Review Report as drafted and we look forward to continued collaboration to strengthen California's nursing workforce and to protect the patients we serve. Thank you for your time and consideration.

Thank you.

Hello, I am Melanie Rowe. I'm a CRNA certified Registered Nurse Anesthetist and I serve as a Practice Director for the California Association of Nurse Anesthesiology.

Along with the support that we have for the APRN to RN regulation, we also support any move that California makes towards the consensus model framework for APRNs to best support professional consistency leading to increased access to care. Canna also appreciates number 24 on your report.

Nationally we have been advocating for the nurse anesthesia profession to be included in the definition of professional degrees. Due to the rigor and intensity of CRNA doctoral programs, they can carry heavy tuition costs. Exclusion from the higher student loan cap will have a devastating impact on the future CRNAs here in California.

The ability to afford nurse Anesthesia programs and exacerbate access gaps to essential health care for the patients with the greatest needs. Thank you.

Thank you.

Good morning. My name is Chris Radford. I'm a certified registered nurse anesthetist at Kaiser Roseville Hospital here in Sacramento. I want to reiterate the last two speakers and just agree with them about the BRN Sunset Bill that's being passed specifically highlighting issue 13.

It is of vital importance that we are able to help our health care system run more smoothly by being able to delegate to nurses. We are very appreciative of all the nurse the work that our nurses do and without them we couldn't be able to do what we do.

In the same vein we in emergent situations, nurses look to us as leaders in the situation, whether it's a team based approach or not, whether it's independent practice that we are working in to be able to provide guidance for best patient care.

The other day I was working at 2 o'clock in the morning and I got a call for an IV, an epidural and a C section within a half hour period. During that time I was able to delegate responsibilities that were appropriate to the nurse.

I started the IV And I let them finish up their lab draws that were already ordered. Then I moved on to do the epidural. And I was able to delegate to the nurse to take blood pressure medications to ensure the safety of the mom and the baby. She did really well, by the way.

Then I went over and did the spinal for a C section. This is the way that Anesthesia works in the current model system. And it is important that we have that in our verbiage for the BRN. And thank you guys for your time.

Thank you.

Hello. Good morning, Chairs, Assemblymember Berman and Committee Members. My name is Diana Hakula and I'm a certified registered nurse anesthesiologist and I'm practicing in Northern California. I'm a professor where I teach doctoral students in nurse Anesthesia. I am also a clinician at a Kaiser facility as well as a sole provider in a rural association.

So I would like to underscore the critical Importance of issue 10.7 and the clarification it provides regarding APRN to RN delegation in rural critical access hospitals where the nurse anesthesiologist may be the sole anesthesia provider on site.

The ability to direct RNs efficiently and clearly delegate responsibilities to RNs is essential to safety, efficiency and keeping surgical services available within that rural community. Without the clarity of care, care would be delayed or services may not be offered at all. Regulatory ambiguity does not protect patients.

It can delay care and discourage providers from practicing in rural areas. We heard a lot of you speak about the rural areas within California. For these reasons, I respectfully urge your support of the BRN Sunset Report as written. Thank you for your time and consideration.

Thank you.

Good morning. I'm Greg Crawford. I'm a certified registered nurse anesthesiologist practicing at Kaiser Permanente in South Sacramento. I agree with everything that my colleagues that preceded me, the points they've made, particularly the APRN to RN delegation. Appreciate your time and your consideration.

Thank you. And thank you for just seconding what other folks have said. We've got another three boards to get through today, so don't hesitate to just say I agree with everything that my prior speaker said. Thanks so much.

Good morning. My name is Allison Bauck and I am a certified registered nurse anesthesiologist, independently practicing in Fresno County, California Community Regional Medical Center. I strongly support the California Board of registered nurses nursing's 2026 Sunset Review report as drafted, and I respectfully urge this Committee to adopt this recommendation without amendments.

I want to quickly provide an example to highlight this importance which was relevant just Yesterday as I served in the operating room as an independent Anesthesia provider. After safely getting my patient through surgery, I transported them to the recovery unit.

I gave a detailed handoff to the PACU nurse while remaining responsible for Anesthesia related orders and oversight with each patient. I direct the recovery nurse to continue specific monitoring parameters, titrate oxygen within defined limits, administer medications as ordered, or notify me if certain clinical thresholds are met.

As the patient remains stable, I began preparing for the next surgical case while remaining immediately available and accountable for Anesthesia care. That coordination is essential to operating room efficiency, reducing patient wait times, and ensuring that Anesthesia professionals can safely care for multiple patients across the perioperative continuum.

As the sunset review report notes, the ability for APRNs to direct RNs is critical from both an operational and access to care standpoint. I strongly agree. For these reasons, I respectfully urge your support of the BRN Sunset report as written. Thank you for your time and consideration.

Thank you very much.

Good morning Dr. Daniel Bell. I'm a practicing nurse anesthetist in Vacaville, California. I'm also the Associate Program Director for Samuel Merritt University which teaches and trains nurse anesthetists.

My colleagues have said it better than I could, so I would like to reiterate exactly what they said and respectfully urge the board to adopt the language as proposed and written by the BRN in their Sunset review.

Thank you. Thanks for setting a good example.

Good morning Chairs and Committee. My name's Josh Carr. I am a CMA, a former army medic, a former army nurse, and a current faculty member at the University of Southern California where I train APRN CRNAS as well.

And I would like to 2nd and 3rd and 4th and 5th the comments of my predecessors by saying I urge the support of this Committee for the Sunset Bill as written and I do want to thank the leadership of the BRN as well for being very thoughtful in terms of crafting this document and thank you very much.

Thank you and thank you for your service. And I see the line is somehow growing. I don't know how that happened.

Hi there, My name is Miguel Reyes. I've been a cardiac ICU nurse for 12 years and I'm currently a second year nurse Anesthesia resident at a doctoral level program and currently training at St. Joseph's Medical center in Stockton. Here to emphasize the importance of issue 13.

We've heard it plenty of times before, but I strongly urge that we get your support. Thank you. Thank you.

Good morning Chairs and board Members. My name is Sean Chester. Like Miguel I'm a nurse anesthesia resident training to become a certified registered nurse anesthetist. And I also would just like to reiterate everything everyone has said before me. Issue 13 is what we want our support on.

Thank you guys so much for your time and have a great day.

Thank you. Appreciate it.

Mr. Chair and Members, Monica Miller on behalf of the American Association of Nurse Practitioners and briefly, we want to thank the BRN for their work and their leadership with regard to putting this report forward.

We look forward to working with both the BRN as well as Senate and Assembly Business and Professions Committee and your staff, particularly where we align our national standards and best practices. And thanks for your time today. Thank you.

Good morning, Chair and Members. Karen Stout here on behalf of the California Nurse Midwives Association, or CNMA. CNMs are advanced practice RNs. I'll be able to briefly comment on issue 11. CNMA is in support of streamlining nurse midwife license and furnishing renewals into a single application instead of two.

Furnishing is a core competency of nurse midwives and a skill set normally expected as a part of that role. Integrating prescriptive authority into the core licensure process is practical, efficient and overdue. I won't belabor the point of issue 13.

We'll just say we're in support of the statutory changes to authorize nurse advice to delegate to rns as appropriate to the scope of licensure, particularly on issue 24. I just wanted to note that CNMA is very concerned about the federal loan limits that are being imposed by HR1, which are still under final consideration.

These will significantly reduce access to federal loans, decrease accessibility of graduate education for advanced practice nurses, including CNMs, either by either forcing students to take out more expensive private loans or forgo graduate nursing education altogether.

We anticipate increased decreased enrollment from individuals from diverse socioeconomic backgrounds and accelerated shortages, impeding our efforts to build a diverse, well prepared health care workforce for all Californians. We request that the brn, the Legislature and HCA continue to monitor the ongoing threats to the growth of our healthcare workforce. And we appreciate your time. Thank you.

Thank you. Good morning, Chairs and Members of the Committee. My name is Mark Pawhead. I have my doctorate in nurse Anesthesia practice and I am a CMA. I'm also a former EMT, a former Orange County Sheriff's Deputy and certified in Tactical Medicine.

I've been a CRNA for 28 years and I currently work in a hospital setting in Orange County and also working in an ambulatory Surgery center as an independent practitioner in Los Angeles. Cannon and I strongly support the California Board of registered nursing 2026 Sunset Review report as it was written.

And I cannot, I'd like to really just emphasize the critical Importance of issue 13. Thank you for your time.

Good morning Committee Members. My name is Romel Yuniza. I'm a independent nurse anesthetist working here in the Sacramento area, also a U.S. army veteran. I will just echo everything my colleagues have eloquently put out before you. Thank you.

Thank you.

Thank you. Thank you for your service.

Good morning. My name is Brent Sachs. I'm a licensed paramedic in the State of California and also a doctorally prepared certified registered nurse anesthetist and independent practice in the Los Angeles area working in ambulatory surgery centers. I just want to say I strongly support the California Board of registered nursing's 2026 Sunset Review Report as it's drafted.

And I respectfully urge this Committee to adopt this recommendation without amendments. Thank you.

Thank you.

Good morning Chairmembers. JP Hanna with the California Nurses Association. Just want to start by saying we appreciate the questions and comments from the Committee and the Board of Registered Nursing, particularly around supporting the nursing workforce pipeline and our new graduate nurses.

Community college nursing programs train a large share of the state's registered nurses and they created an affordable, accessible path into the profession. Our community college ADN programs also draw students from diverse backgrounds, low income communities and rural regions, making these programs essential to building a nursing workforce that reflects California's diverse patient population.

Supporting ADN new grads means strengthening one of the most important entry points into California's health care workforce. Many of these rural and underserved and high needs communities continue to face RN staffing staffing difficulties. New graduates often work but want work.

But practical barriers like job access, relocation costs, housing, transportation and other transition costs can make it harder to start practice where they are needed most. We look forward to working with the Legislature on strengthening pathways for community college nursing education to community based care in our role in medically underserved communities so

that we can expand opportunities for our ends and ensure communities have the care that they need. Thank you very much.

Thank you.

Good afternoon. I think almost Liz Bambouchet on behalf of California Association of Nurse Anesthesiology. Great to see so many of you in person again and just wanted to submit my support to keep the language as drafted without amendment for the BRN Sunset. And thank you to our BRN leaders who are making this happen.

Thank you.

Hello, Jeff Darnoff, from the University of Southern California. I'm a certified registered nurse anesthetist and an acute care nurse practitioner and a program administrator for the USC Program of Nurse Anesthesiology.

I want to again thank the Board of Registered Nursing for all of their work and effort and reiterate what my colleagues have said in their support of item number 13. Thank you.

Thank you. And fight on.

Good morning. Thomas Batchelor, CRNA, of the Los Angeles and San Bernardino Counties. I also wanted to express my support of the BRN language as written. And thank you to the Committee Chairs Members and to the BRN. Thank you.

Thank you.

Thank you. Sandra Borde, last but not least, certified registered nurse anesthetist. I give anesthesia in Southern California, Kaiser. And I'm one of the program faculty at one of the nurse anesthesia programs in California here. First of all, I just want to really thank Executive Officer Lori Melby and the BRN for creation of the CRNA Advisory Committee.

It's been very instrumental and having nurse anesthetist experts who can advise the practice Committee on concerns that are brought from the public. So thank you for that. We really appreciate that. And ensuring safe, high quality, accessible Anesthesia services throughout California.

And similar to my colleagues that were up here, I'd like to again support as written the language in regards to the APRN delegation to rns. Thank you.

Thank you. And are we double dipping?

We're double dipping.

Sorry for.

I'm here now for the American Nurses Association of California. And I just wanted very quickly. #MeToo. In terms of the comments, in terms of nursing students, studies show 30 to 40% are leaving within two to three years after getting into the field. But nursing faculty is a huge issue.

So many are retiring and we don't have a pipeline behind them.

Thank you.

Thank you.

Thank you everybody for your patience. Thank you for the presentation and the answers. Thank you to my colleagues for all the questions. Thank you for everybody who is not here for the BRN for your patients. We're going to move on to the physical therapy board.

Next we will be hearing from Jason Kaiser, Executive officer, Dr. Karen Brandon, board President, and Dr. Dale Armstrong, board Vice President, who I believe will be joining us remotely. So hopefully the tech works and we can get that rolling.

And do we have Dr. Armstrong? Coming in remotely, or is that maybe just going to be via phone call? I don't know how we're doing this. Webex. Got it. We can see Dr. Armstrong. We'll get to... I'll defer to you all on the order of your presentation. Please go ahead.

Thank you. Good morning, Chairs Berman and Wahab and the distinguished Members of the Committee. My name is Dr. Karen Brandon, and I'm honored to serve as the President of the Physical Therapy Board of California.

Thank you for the opportunity to appear today as part of our 2026 sunset review oversight hearing to discuss the Board's work in protecting the people of California. The Physical Therapy Practice Act was established in 1953, and today our board is comprised of seven diverse members.

Four Governor appointed professional members, one Governor appointed public member, one Senate appointed public member, and one Assembly appointed public member. And we currently have two vacancies. Our mission is clear, to advance and protect the interests of the people of California through the effective administration of the Physical Therapy Practice Act.

Public protection remains our highest priority and guides every licensing, regulatory, enforcement, and outreach decision we make. The Board currently oversees more than 41,000 active licensees including physical therapists and physical therapist assistants, representing about 15% growth rate since 2021 when we were last here. We are well above the national average, reflecting continued expansion of the profession statewide.

California is home to 19... California... I'm sorry, 19 CAPTE accredited physical therapy programs and 27 CAPTE accredited physical therapist assistant programs, all of which have a 90% or higher pass rate for the National Board Exam. We are doing our part in supporting a strong and growing workforce pipeline.

In addition, the board recognizes 125 continuing competency approval agencies, helping to ensure that licensees maintain ongoing professional competence throughout their careers. Over the last year, we have continued to strengthen our core responsibilities, improving licensee efficiency, maintaining rigorous enforcement standards, advancing thoughtful regulatory updates, and engaging proactively with the stakeholders.

We recognize the challenges Californians and licensees face in accessing timely, competent care and we remain committed to fostering a regulatory environment that balances strong consumer protection with practical workforce realities. We also value the collaboration of licensees, patients, educators, and professional associations, and public members whose input actually strengthens our deliberations and informs sensible regulation.

The Board takes seriously its responsibility to be transparent, accountable, and responsive to legislative oversight. We are confident in the progress we have made and remain committed to continuous improvement in the service to the public. With that, I will turn over to our Vice President, Dr. Dayle Armstrong, on Webex to share further detail regarding the Board's implementation efforts and stakeholder engagement.

Great. Thank you very much. And Dr. Armstrong, hopefully we can hear you. Unfortunately, we can't hear you. Does it happen to be muted on your end? And we lost video. We can see you, but I'm not sure we can hear you yet. Yeah, that's a good question. Can you hear us? You can hear us. Gotcha. That's half the battle.

I assume it's... I don't know what tech support we've got behind the walls, but... So thinking that you're not, you're off mute on your end. Yep. But for some reason it's not working. Paging the magicians. We're not getting audio. Yeah, thanks. So we will try to get this figured out. We've now exceeded my expertise.

So I think we're going to try to see if maybe you can join from another device, if that's possible, or maybe sign off and resign in again. So our tech magicians, I think, are communicating with you to try to get it sorted out. In the meantime, we're going to move forward and hopefully we'll get this figured out as quickly as possible. Any additional comments in your presentation?

I would just say good morning, Chair Berman. Good morning, Committee Members, consultants, and staff. And a thanks to all the IT folks in the background that are making this happen. And thank you for giving us the opportunity to participate in the sunset review.

As the Executive Officer, the Administrator of the Board, I'd just like to highlight that the report that was submitted to the Board or to the committee in support of its continuation is more than just data, statistics, and narrative. It reflects the commitment and ethic of this board's members and staff to the ongoing mission of protecting the people of the State of California.

And more importantly, protecting the consumers of physical therapy services in the state. So whether it's through our application or licensing services staff, our consumer protection services staff, or the staff of our administrative and executive services unit, it's clear, as I think you'll see through the report, that they strive to live up to the vision being the standard of excellence in consumer protection.

So while I have this brief moment of airtime, I'd like to thank them personally. I'm very proud of the job that they do, and it also makes my job as the administrator a little bit easier. I'd also like to extend thanks to our other partners in this mission, the Department of Consumer Affairs, for their support.

The DCA's Division of Investigation. Oh, closer. The Department of Justice's Office of the Attorney General, and our brother and sister boards at the Department of Consumer Affairs. So, again, thank you, and we're happy to assist and answer any questions you might have.

Wonderful. Thank you very much. Going to turn it over to colleagues for any questions or comments that they might have. Senator Archuleta,

Yeah. Thank you for being here. I'm so sorry we can't hear from your Vice President, but I'm excited that you're here. Because physical therapy after, you know, it's a rehabilitation, we all know that. And after the operation and everything goes done with whatever it is, physical, emotional, whatever it is, you're turned over to someone else.

No longer had the nurse, the doctor, but now you have to take over. Tell me about the relationship you establish with the patients during the process, when you finally get, when they finally get released, and how important that is. What exactly is your mindset when all this is going on?

Thank you for that question. As a practicing physical therapist, I do believe that the relationship and creating a safe and professional relationship with the patient goes a long way. Not only do you have to garner trust for the process, some things are uncomfortable, and some things are things that you're doing with a patient that are unfamiliar to the patient. But they have to believe you, not only in your credentials and your expertise, but that you actually care about them.

So that relationship also transitions into how effective your practice and your recommendations are going to be with them because many of those things have to go on to be lifelong practices that they do to maintain their level of function, to continue to improve physically. So it's both of those things are important. The ability to convey your expertise, but also the awareness that you care about the outcome and you care about them as people.

I would imagine some of the patients that are stroke victims, heart attacks, you know. We talk about physical therapy, knees, back, whatever. But these strokes and the ability to speak again and to move your hands again, that's got to be devastating for the patient and the family. Do you find that you have those that are a little more familiar with that type of work versus some of the others within the realm of your agencies?

Yes. So definitely. This is very close to home. My father sustained a stroke three years ago, very profound one, affecting multiple functions. In my practice and in my education as a physical therapist, noticing maybe even early signs of compromise of blood to the brain. We learn those early, like cues.

Number two, going into the acute care and making sure that those providers are part of the medical team that helps the patient with early mobility and make sure they have good circulation and also follows the practices that are necessary to keep people safe in the ICU.

Moving forward to the rehab facilities. Many of those therapists, physical therapists, and physical therapist assistants are trained in neurological rehabilitation. So it's not just getting somebody up and walking.

It's how to engage and facilitate certain parts of the body that are important as the baseline to them being able to recover. Whether it's working on trunk motion or working on their breathing or working side by side with occupational or a speech therapist to do collaborative care and definitely making sure that the family is involved. Right.

And then, of course, there's home health services and outpatient rehab that continues to progress the patient to the fullest extent of their function. So not only have I had the opportunity of working in multiple settings and implementing those for neurological patients, but I've also been on the other side as a family member and seen the benefits. And I'm very thankful for those physical therapists that worked with my family.

I want to thank you again. I don't think we give you enough credit, and I certainly acknowledge because I have family members have gone through it, both physically, emotionally, and so on. And the therapist is the one that met him at the door and then said goodbye and just keep up therapy. Well, thank you.

Thank you.

Thank you, Senator. Any additional... Senator Smallwood-Cuevas.

Thank you so much. Good morning. My question has to do with AI. I noticed that in my, in some of the reporting and materials that the use of AI is becoming more prevalent in your practice area. Would love to hear a little bit more about that. I always get concerned when we have AI being integrated into our health care field.

We hear so often from nurses, for example, of, you know, technology being wrong and too often overriding the human knowledge and expertise. So I'm just curious, how are you integrating this technology in? Are there particular consumer protections that the board feels is essential for us to consider, and particularly around making sure that there's proper enforcement, too, when these tools are utilized and problems arise?

First, I would say that AI is an emerging tool to be used by practitioners across all of healthcare. And we do see it in physical therapy. Really, when you look at things in the larger context, even delivery by tele-means is somewhat new, right? We've just experienced that over the last 10 to 15 years.

Most importantly, during the pandemic, we saw that kind of rise in height and access. We utilize the same philosophy and enforcement for those type of complaints for telemedicine. Telemedicine is just a tool that the practitioner can use, but it should never replace the standard of practice.

You can take that same idea or methodology and apply it to artificial intelligence. So, we would hold the licensee practitioner who is using AI in that model responsible and that fact checking and making sure, just like we provide guidance or we also receive guidance from every large language model for provider, that you should check it.

It can hallucinate; it can be wrong. Right? So, our practitioners have to do the same thing. From the board's perspective, we also want to educate the public in kind of that caveat emptor mentality of buyer beware.

We do see the emergence of the separation of licensee and AI where the actual delivery is being done almost at the corporate level by an app of some kind or a website. And in those instances where we receive complaints, we investigate them like we would any other unlicensed practice complaint.

And to the extent that we find physical therapy services being provided by one of those entities, apps or corporations, that's not actually tied to a human licensee, we would pursue that unlicensed practice route. I do predict in the future that that will probably become a more prevalent problem for us.

And there might be some—maybe a greater deterrent than what we currently have in just issuing a citation to someone limited to a $5,000 fine for unlicensed practice, because that might not serve a great enough deterrent to those larger profit-bearing corporations. They might see that as a ticket to be paid.

I also want to say, you know, the practice of health care in general is seeing a boost in three different areas, I would say, for AI. The first one, obviously generative AI, which is your typical, hey, I have something wrong with my shoulder. What are the exercises I should do?

And that, certainly, as Mr. Kaiser says, the buyer beware and we definitely want to make sure that consumers are aware, but also, practitioners and licensees are not allowing these new innovations to replace the judgment that we, as the State of California, have put in that license for them to give to an individual. The second one would be predictive AI.

So, predictive AI is, okay, if this person has this problem and this problem, they likely need this thing. And certainly, those are still in the works. Regarding research, we utilize a lot of it in statistics when we're doing predictive models for disease, but I don't think we're utilizing it currently with actual care.

The final one would be assessment models. So, the ability for us to put markers on a patient's body and be able to evaluate their gait and see if they could change something about their running speed or how their utilizing certain muscles.

And that really doesn't have a direct correlation yet with practice, but it's definitely another area that physical therapy is active in that the AI wave.

Thank you very much. Any additional questions or comments from colleagues? Couple thoughts and a question. One, I've used AI to try to help kind of diagnose physical injuries. And I should say I didn't appreciate physical therapists as much in my 30s as I do in my 40s.

So, I feel like I need one on standby these days or I just need to stop exercising. But, but, I felt like it did a decent job of helping me understand what the, what, what injury I'd sustained. But then I've also used AI in lots of other ways where it's been so wrong.

So, I appreciate the buyer beware comment. You know, we need to be—that can be a good place to go maybe for an initial little guidance. But you've got to go get do, do more, get more professional advice, especially when it comes to our bodies and injuries that we've sustained.

Wanted to ask about issue one, which is the issue of statutory caps. And looking at issue one, the Board's request for a statutory fee increase, what steps would the Board take when increasing fees and regulations? For example, what would trigger the Board to commence rulemaking?

And I'll note that the Board has, has asked for increase in the statutory cap before. It turns out it hasn't been needed. That's a good thing. It's a good thing that you haven't needed to increase the statutory cap in the past. But help me understand a little bit about the request this time.

And in addition to that, how does the Board handle opposition to a fee increase during the comment period?

Sure, I'll take that question. And you're right, I was before you this time, five years ago, asking for this cap and I'm pleased to say that we didn't need it. It's a good thing. Those anticipated costs are a bit of a stressor. So, but times have changed a little bit.

We have and are now struggling with just the general cost of living and cost of doing business that every other consumer in the state of California is experiencing.

To your question about where we would go after a cap authorization was provided to us, through the promulgation of regulation process, staff would do a research paper into determining what the actual fee would be required to sustain operational need moving forward.

You'll see in the briefing paper and in the sunset papers that we talk about our fund condition. And currently, our fund condition is about seven months, but projections show it kind of starting to diminish over time each and every year. As the administrator, I have had the unfortunate experience of having to raise fees in the past.

And in that particular experience, we waited until we got down to a three-month fund condition before we started that process. So, I don't know that I would wait quite that long this time, but we would also take an incremental approach. Right?

So, not the assumption being if that VCAP was granted, the assessment through the regulatory process would be much more specific based on operational need. What will we need to sustain operations moving forward? Because we can always address this issue in another regulation, you know, past that point.

What I see as kind of being an issue is that this board still suffers a little bit from, from growing pains and the size of its staff commiserate to the size of its licensing population. And, but I'm happy to say as a profession and as a regulator of that profession, our population continues to grow year after year.

And not all, not all boards can say that. So, in that situation, with more licensees, you have the potential for more information sharing, more complaints received, more investigations and have you, hence more costs, and that's where we find ourselves today.

Gotcha. Thank you very much. I know we've had a couple of additional colleagues join. Any questions for the Board of Physical Therapy? The Physical Therapy Board. Yes. Yeah. Assemblymember Alanis.

Yes, thank you, Mr. Chair. So, if I may ask, the committee's analysis notes on page 27, the dry needling that's allowed in most other states. What has been the experience in terms of malpractice claims and licensing actions involving PTs who use this technique in states where PTs are authorized to use this technique?

Okay, so just for clarity's sake and to be clear, dry needling is currently prohibited for our physical therapists here in California. As far as malpractice claims pertaining to dry needling modalities in other states, I don't have that data. But I can tell you just anecdotally, malpractice claims for physical therapists are low, in consideration of other healthcare practitioners.

I know that also you'll see throughout the issues paper that we recently became aware of a modernization of the Practice Act Bill by the California Physical Therapy Association. And one of the items that they are seeking in there is the authority for physical therapists in California to do dry needling.

And it's something that we'll have to work with them, you know, moving forward. It's been an ongoing topic for this board for about the last 10 years. We've had two stakeholder engagements about dry needling.

Just for clarity's sake, just to make sure that all of our consumers, all of our licensees, and all of the licensees of other professions that have overlap understand what the actual laws say and if there are prohibitions for our practitioners being able to use that particular modality.

I also wanted to add, if it came to the rulemaking, if this actually became part of the Practice Act, we have really been engaged with multiple states in how they evaluate competency. I think that's really important. And also, you know, what their relationship is with the other stakeholders in that state regarding the use of penetrative procedures.

I have one more, if I may.

Always.

Okay, thank you. So, we've had a lot—we've had some laws allowing patients directly access physical therapy since 2013, and there's an analysis—again, and this on page 21.

I'll just go straight over to states allowing it without the restrictions of California that has, which is the 45 days, the 12 visits, or whichever one comes first. What has been the experience in those states, if you guys know, and are there any data that shows that PTs are inappropriately treating patients or not referring to physicians or other providers when it's appropriate for the patient's conditions?

They, for direct access, for those states that have true direct access, I can tell you that the data that I have available to me is it would be this, the disparity between complaint intake per population and I don't see that in those states, in particular, that there are any kind of anomalies that cause me concern.

When we, when we did transition, I was here when we transitioned from no direct access to temporary direct access, and it was a little bit of a roller coaster ride. Right?

We thought that there was going to be a little bit of the wild, wild west, but I'll tell you that it didn't turn out to be that way. Right? We were a little—we were pleasantly surprised that 12 visits in 45 days worked so well in partnership and communication with the diagnosing physicians.

And then we transitioned through the pandemic. And during that pandemic, access to care was a great issue.

And one of the things that we made in a recommendation to our previous sunset is for that direct access, past that 12 days or 4—or 12 visits or 45 days—the patient would have to have an in person consultation and evaluation by the physician and have the physician sign off on the planet care before the physical therapist could continue care.

You can imagine during the pandemic that was practically an impossibility. And so, one of the recommendations that we made was to shift from in person to a telemedicine or a tele-means evaluation when clinically appropriate by the physician. That went into effect as a result of our 2021 sunset. And it also has worked very well.

I wanted to mention too, I think a big part of that change, if it happens in California, really will be reflected in our ability for consumers to access us and to know what to expect when they have physical therapy and what they shouldn't expect.

And we utilize a lot of online available messaging and also, the mandated requirement for all physical therapy practice in designated areas to have our access 1-800 number for complaints or questions or concerns. So, I think it's also keeping the consumer aware so that we can maintain that connection and openness to any questions or concerns.

Hello, can you hear me now?

We can. We'll be with you in one second. But I'm glad we can hear you.

I'm good, Mr. Chair.

Thank you, Assemblymember Alanis. Any additional questions or comments from colleagues? Vice President, Dr. Armstrong, we can hear you. We would love to hear your testimony.

Hello. Would it be all right with you for me to present my introduction?

Yes, please, go ahead.

Thank you so much. Thank you, Dr. Brandon. My name is Dayle Armstrong, and I am a professional member of the Physical Therapy Board and I currently serve as Vice President. Physical therapists in our communities continue to provide services to our diverse populations to improve their quality of life and to maximize functional ability.

The Physical Therapy Board continues to prioritize strategic planning for operations alignment with its mission to protect the public. During the current sunset period, the Board completed nearly all objectives in its 2018-2022 strategic plan. Highlights include objective tracking, cross program participation, facilitation of public engagement, strengthening internal processes, and adoption of the 2024-2029 strategic plan.

The Board's implementation efforts include staffing enhancements, creating positions to support licensing operations, consumer protection, and a dedicated military liaison to assist applicants in inquiries. Stakeholder engagement includes participation in the Federation of State Boards of Physical Therapy, expansion of digital platforms to keep the public engaged.

And in 2023, the Board launched a redesigned website focused on improving user experience. In addition, the Board participates in community and educational events, along with presentations to PT and PTA degree programs to California schools and universities. Jason Kaiser has continued to serve as Executive Officer, providing consistent and mission-focused leadership.

In October 2023, the board enhanced operational alignment resulting in a dedicated executive unit. By centralizing functions, responsiveness, stakeholder engagement, and governance support are enhanced. And I very much appreciate you allowing me to speak out of order.

Thank you very much. I'm glad that worked out. So, with that—thought I heard the voice of God. We're going to open it up to members of the of the public or advocates who have any comments. As a reminder, please keep your remarks at two minutes. Please go ahead.

Yeah. Mr. Chairman and Members, thank you. Carl London here on behalf of the California Physical Therapy Association. I want to say that first of all, we have a great relationship with the Board. I will tell you it does not mean that we get everything we want there. I assure you of that.

That's not the case, but they do a good job. For us, access and access to care and safety are number one. You should know that there is, in California, a shortage of PTs to handle the population's needs.

The good news is that we have, as the board indicated, over 20 schools that are now training and educating physical therapists and PTAs, Physical Therapy Assistants, to provide services throughout California. One of—and that the PT level, since 2015, they've been educating to the doctorate level. So, they're now getting a doctorate in physical therapy.

They're being trained to practice independently, for patients to come in directly to see them, to do things like dry needling that was raised. The difficulty is in this state, there is a gap between the education training and the actual practice of what they're allowed to do based on the law.

Now, this law has been around since the 1950s. It has to be updated periodically.

And we're kind of at one of those critical junctures because the problem for us is that as students come out of these programs, if they can't do things that they're interested in doing, that they've learned to do, that they've been trained to do, they will leave, they will go to other places where they can form these acts.

Dry needling, as the report indicates, is allowed in 46 states. There's only four states that prohibit it, and California is one of them. Is that something we really need to do? If you talk about pilot projects, we've had a huge pilot project going on for years.

The malpractice data, the licensing complaint data on dry needling is non existent. It is not a problem. Where we're seeing problems in care that are delivered in those other states, we use the same malpractice carriers. The other states, we would know that and see it. It doesn't exist.

Another issue that comes up is physical therapists are being trained to know when to order imaging. So, X rays, scans, MRIs, things like that. We do not ever seek to interpret those. We do get trained to do that, but a radiologist always interprets those images.

But when you're having a patient come in directly and you're trying to evaluate and assess their needs and what you can offer them treatment wise, there are occasions where you need imaging to help in that process because that may help you push the patient right to the other appropriate provider.

Thank you, Mr. London. If you could wrap up.

Last thing I'll say in this then is that regarding the Board's push for a fee increase, we're neutral on that. It comes at a tough time. You guys know we sought legislation to curb some of the practices and prior authorization. Payments right now are not going up for physical therapists. Costs are.

So, having a fee increase at this time is tricky. However, we totally understand the Board's need for funding to be able to do its job. And so, we're, you know, patiently neutral, I'd say. Thank you.

Thank you.

George Soares with the California Medical Association. Just wanted to highlight one issue, that's issue number six. As a—we're concerned with all the provisions within issue number six as it relates to expanding the scope of practice for physical therapists, so, we'll continue to monitor that to ensure there is no patient risk with that. Thank you.

Thank you.

Good morning, Chairs and Members of the Board—I mean of the Committee. My name is Karen Atlas, and I am a licensed physical therapist and owner of Atlas Rehabilitation for Canines in Santa Barbara where I work together with veterinarians helping animals recover from orthopedic injuries, neurologic disease, and surgery.

I also serve as the President of the Animal Physical Therapy Coalition representing veterinarians, physical therapists, veterinary technicians, and animal welfare advocates. I am here today because a regulatory gap that has persisted for more than 20 years limits access to care and workforce utilization. I appreciate that the Sunset review backgrounder identified this issue under, under issues number seven.

Across the country, animal physical therapy is recognized as the practice of physical therapy when performed by licensed PTs with additional education on animals and under veterinary referral, consistent with the national standards established by the Federation of State Boards of Physical Therapy. However, our regulatory framework remains out of step with national standards.

Licensed PTs providing rehabilitation to animals are currently classified as unlicensed veterinary assistance requiring direct veterinary supervision. The PT Board has suggested this issue belongs under the VMB, but that approach has already been tried and failed. Two legislative efforts, AB 3013 and AB 814 with Assemblymember Lowenthal, attempted to include PTs within the Veterinary Practice Act.

Both were opposed by the VMB, leaving the regulatory gap unresolved. In 2022, the VMB removed a veterinarian's ability to determine supervision levels and mandated direct supervision, placing previously lawful collaborative practices out of compliance and raising concerns about anticompetitive regulatory effect and reduced access to care.

States such as Colorado recognize that PTs providing rehabilitation under veterinary medical clearance are practicing PT and remain accountable to their licensing board. No complaints of harm—of animal harm—have been reported across the country demonstrating its safety.

If you could wrap up, that'd be great.

I respectfully ask the Legislature to establish clear statutory authority so licensed PTs with advanced animal training can collaborate with veterinarians. If sunset review is not the appropriate vehicle, I ask for your support in separate legislation. Clear rules protect consumers and expand access to care. Thank you.

Thank you.

Good morning, Chair and Members and thank you for the opportunity to speak today. My name is Dr. Jenny Moe. I am speaking on behalf of the Animal Physical Therapy Association's Animal Physical Therapy Special Interest Group for which I am the Vice President. I also own and operate a custom animal wheelchair company called Dog on Wheels.

I'd like to provide a personal perspective related to, I believe, issue 7. I've been a licensed PT for 23 years, certified to work with animals for 16, where I focus my practice in the San Francisco Bay Area. I worked in specialty veterinary hospitals in the Bay Area as part of a cohesive team.

In 2018, I decided to move to Stateline Nevada where I was able to open my own practice as I could not do so in California due to current regulatory restrictions. The Nevada model worked beautifully to allow PTs and veterinarians to collaborate and expand access to PT services.

I was able to help a wide range of animals including post op patients, canine athletes, neurological and orthopedic patients, and search and rescue dogs. However, I continue to face limitations as vets in South Lake Tahoe cannot directly refer to me as a non veterinary professional without additional expense and time to the client.

Upon returning to San Francisco in 2020, I've been unable to fully practice animal PT unless I'm employed directly by a veterinarian. This restriction persists despite my license or training and decades of experience. The wait time is about three months in the Bay Area.

We are lucky to have many options, but everyone is backlogged with a surplus of clients. The long delay may lead clients to find self-service options that provide a generic treatment plan that may not be safe for the patient in question, whether that be from AI online forums or word of mouth.

To Berman, I actually have the pleasure of collaborating with veterinary colleagues to serve a lot of constituents in your own district, especially along the coast. Clients are desperate for in home services and skilled rehab in general. I have submitted letters to your office alongside some of my clients and those vets to your district to support my statement today.

I look forward to a day when animal PTs are able to serve our clients and patients freely under proper regulation, ideally under the Board of Physical Therapy.

We hope to be able to collaborate with the veterinary field to do what we all set out to do, make the lives of the animals we love the best it possibly can be, for as long as possible. Thank you.

Thank you very much.

Thank you, Mr. Chair and Members. I'm Christina DeCaro, lobbyist for the California Veterinary Medical Association. I just wanted to indicate CVMA's strong opposition to the concept of opening up the Physical Therapy Practice Act or the Chiropractic Act, which you'll hear next, to allow physical therapists or chiropractors to work on animals without proper veterinary supervision.

Your comprehensive background document notes how current law actually does allow a physical therapist or a chiropractor to work on animals in a safe and controlled environment, as long as they are under veterinarian oversight. And that structure has been working very well for many, many years. We see no reason to change it now. So, thank you very much.

Thank you very much. Seeing no additional comments from the public. Thank you for your presentation and for your answers to all the questions that were asked. And we're now going to move on to the Board of Chiropractic Examiners. Thanks so much.

So, for the Board of Chiropractic Examiners, we have Board President Lawrence Adams and Executive Officer Kristen Welker here today and we're ready whenever you are.

That better? All right. Excellent. Good morning. Good morning, Chair Berman and esteemed Members of the committees. My name is Dr. Lawrence Adams. I am the Chair of the Board of Chiropractic Examiners. With me today is our Board Executive Officer, Ms. Kristen Walker.

I am a second generation chiropractor, a small business owner and a diplomate of the American Chiropractic Neurology Board. I've been in private practice in Sonoma for 31 years and have served on the Board since October of 2020. The board was recruited by a voter approved initiative measure in 1922 to regulate the practice of chiropractic in California.

Our mission is to protect the health, welfare and safety of the public through licensure, education, engagement and enforcement. With a vision of ensuring California consumers receive high quality patients, patient centered and collaborative care. The board oversees approximately 12,000 licensed chiropractors, 20 chiropractic programs across the United States and Canada, and 106 continuing education providers.

Chiropractors serve as primary contact portal of entry providers in all 50 states, meaning patients can directly access their services without a refor or limitation on the number of treatments.

In addition to private practice, chiropractors are increasingly being integrated into medical practices, hospital systems and federally qualified health centers and rural health clinics where they collaborate with existing care teams and increase access to primary care, particularly in underserved and rural areas of the state. Since our Last review in 2022, the board has made significant progress.

We adopted a new strategic plan that focuses on strengthening consumer protection, improving organizational efficiency, and expanding the equitable access to chiropractic information and services. The plan prioritizes modernizing our licensing and enforcement systems, ensuring long term financial stability, enhancing stakeholder engagement, and investing in staff development to support high quality public service.

We later amended the plan to place a stronger emphasis on equity and communication. This includes increasing participation from a diverse range of stakeholders, recruiting subject matter experts who reflect the communities we serve, and improving our digital presence so consumers and licensees can easily access relevant resources.

The Board also created a licensing Committee to modernize chiropractic licensure and practice in California. The Committee developed regulatory proposals to update educational and licensure standards, streamline applications, improve consumer notification requirements, establish standards for virtual care, require basic life support training, and repeal outdated regulations.

We also established a new Subcommitee to set standards for advertising and recognition of chiropractic specialties. Internally, the Board completed a comprehensive reorganization, updated all staff duty statements, and enhance its enforcement program. We created dedicated investigations and case management sections, hired additional special investigators, and implemented video conferencing to reduce timeframes and costs.

As a result, the Board reduced its pending complaint caseload from nearly 600 in 2020 to approximately 180 today, a 70% reduction. We have also advanced 14 regulatory proposals, five of which have already been approved by the Office of Administrative Law.

We thank the Committee for their Collaboration during the last review to strengthen the Patient's Right to Know Act and improve transparency for chiropractic patients. As part of this sunset review, we are seeking statutory changes that will further strengthen consumer protection and ensure the Board can act swiftly and appropriately in the most serious of cases.

Specifically, the Board is seeking authority to consider any prior discipline involving sexual abuse or misconduct when evaluating licensure applications, regardless of the age of that disciplinary action, automatically impose the existing 10 year mandatory revocation for a second insurance fraud conviction, automatically revoke a license following conviction of a sex offense, automatically suspended license following conviction of a serious felony and to automatically impose chaperone requirements during pending criminal proceedings involving a sex offense or or following the filing of an accusation alleging sexual misconduct.

The Board is also seeking to address its projected fund insolvency by 2027-28 and to establish new fee authority for the issuance and renewal of a chiropractic facility permit. This permit would replace outdated satellite certificates, improve transparency by allowing consumers to search for chiropractic practices by business name and provide the Board with more precise practice data to strengthen.

Excuse me. Oversight and enforcement. Thank you very much for the opportunity to present to you today. We look forward to answering any questions the Committee Members may have.

Thank you very much. Any. Please. Would you like to present.

Nothing to add. Just here to answer questions. Thank you.

Appreciate it. Thanks so much. Any questions or comments from colleagues?

Hi. Morning. Quick question about the enforcement. Some of the enforcement issues that were raised. I believe it was under issue area 9. Can you talk a little bit about how how you look at practitioners who may have had some experience with sexual misconduct? What is your sort of review process?

What are the steps that you currently have in terms of issuing a license or not issuing a license and how are you ensuring that there is consumer protection in regards to those individuals who may have the challenge of getting access to a license outside of sexual misconduct just in or nonviolent offenses?

I'm just curious what your review process looks like and what are the barriers to licensing and then how do you ensure consumer protections when there are more serious offenses involved?

I'll take a quick lead on that and then let Ms. Walker add anything. One of our asks as you, as you're pointing out, is related to sexual offense in relationship to licensure and also some strengthening of statutory aspects.

After someone has committed sexual misconduct in ways that we can protect the consumer. In relationship to licensure, one of the things that we're looking for is the focus right now is it sits there's a seven year provision, right.

So if somebody has an offense that precedes the seven years, we're kind of in the dark on that from a license standpoint.

So one of the things that we're asking for is when it comes to a sexual misconduct in that person's past who's seeking licensure, we think the timeframe should be dropped and allow us as a board to look at the rehabilitation and the potential for them to reoffend, rather than just a time frame.

So we want to know the significance of that sexual misconduct. Whether of course, if it was violent or nonviolent. That's also very important. But we feel like we should be able to assess that person about their ability or the rehabilitation efforts they've taken and whether they might reoffend once they have given.