My name is Judy Hackler, and I am with the Virginia Assisted Living Association, also known as VALA. I would like to share comments on SB40. After communicating multiple times with the Virginia Poverty Law Center and other stakeholders regarding this bill, we appreciate the initial purpose of the bill, but we do not support the current language that was published or shared with us at the time of these comments. The language we have seen would not optimally fulfill the purpose and would not serve the best interest of the residents, the assisted living communities, and the Virginia Department of Social Services. As currently worded, there are direct conflicts with current requirements for licensed assisted living facilities. This conflicting language would force facilities to have to pick which requirement to adhere to and which requirement to violate, and the conflicts would also create an issue in enforcement of which requirements to enforce. We have concerns that having conflicting requirements could potentially endanger the residents and the facility staff. For example, assisted living facilities are restricted in § 63.2-1805 D from admitting or retaining residents with certain conditions or care needs. The wording of SB40 would potentially require assisted living facilities to retain residents not allowed under the Code to stay at the facility during an appeal process. This could endanger the resident and staff members caring for the resident and would be a direct violation of the standards. We have requested numerous times that an amendment be made to SB40 to remove the conflicting requirements. Another conflict of SB40 with current requirements is with regards to the timeline for notification. Current requirements state the “resident shall be moved within 30 days;” whereas SB40 states that “at least 30 days prior to an involuntary discharge.” We have requested an amendment to resolve this conflict in language. Again, we have been working in good faith with the Virginia Poverty Law Center and other stakeholders to develop a bill that would be in the best interests of residents, staff, the assisted living facility, and the Department of Social Services, but we cannot support the current wording of the bill. If the Virginia General Assembly wishes, we would welcome the convening of a workgroup to include the stakeholders, such as VALA, and the Department of Social Services that would consider current requirements regarding the discharge of residents in licensed assisted living facilities to make recommendations for improvements to provide a more defined and transparent appeal process for the involuntary discharge of residents in assisted living communities that would not create conflicts with current requirements nor endanger residents and staff. The recommendations of the workgroup could then be presented for consideration during the 2023 General Assembly Session. In addition to the conflicting requirements the published bill language would create, we also have concerns with the fiscal impact to the Commonwealth. As a result, we oppose the bill as currently presented. Thank you.

Requesting information

My mother moved to a nice retirement facility that offered a "continuum of care" with an assisted living wing. About ten years later, one day I was called to come and get her because they were unwilling to have her there any longer because of her diminished mental capacity. I was living several states away and staying in touch mainly by phone, so this was not apparent to me. Fortunately I was able to take time off work to relocate her to where I was living. I didn't know what rights she had, if any, and had no time to think about that anyway. I cannot imagine what it would be like for someone who lacked the time or money to make immediate arrangements. That's why when I read about this bill, I was thankful that it looked like Virginia was taking steps to prevent this kind of upheaval. I see that SB40 would cost the state a small amount, particularly in the first year. There are 26,400 assisted living beds licensed in Virginia. Thus the start-up cost is about $26.44 per licensed bed. I think that's very reasonable for peace of mind. My mother's traumatic eviction was many years ago and she did not live very long afterward. I don't think anyone should be treated like that and I hope you will put a stop to it. Thank you.

My name is Judy Hackler, and I am with the Virginia Assisted Living Association, also known as VALA. I would like to share comments on SB40. After communicating multiple times with the Virginia Poverty Law Center and other stakeholders regarding this bill, we appreciate the initial purpose of the bill, but we do not support the current language that has been presented which would not optimally fulfill the purpose and would not serve the best interest of the residents, the assisted living communities, and the Virginia Department of Social Services. As currently worded, there are direct conflicts with current requirements for licensed assisted living facilities. This conflicting language would force facilities to have to pick which requirement to adhere to and which requirement to violate, and the conflicts would create an issue in enforcement of which requirements to enforce. We have concerns that having conflicting requirements could potentially endanger the residents and the facility staff. Again, we have been working in good faith with the Virginia Poverty Law Center and other stakeholders, but we request the Virginia General Assembly to convene a workgroup to include the stakeholders and the Department of Social Services and to consider current requirements regarding the discharge of residents in licensed assisted living facilities to make recommendations for improvements that provide a more defined and transparent appeal process for the discharge of residents in assisted living communities that would not create conflicts nor endanger residents and staff. We would request the workgroup to present the recommendations for consideration during the 2023 General Assembly Session. In addition to the conflicting requirements the published bill language would create, we also have concerns with the fiscal impact to the Commonwealth. As a result, we oppose the bill as currently presented. Thank you.

I SUPPORT SB 201, 241, 436,

I SUPPORT SB 201, 241, 436,

Comments Document

RE: SB 241, Renal Disease Council and Renal Disease Council Fund (Hashmi) – SUPPORT Chair Orrock and Members of the Committee: On behalf of all the people we serve in Virginia, I am writing to request your support for SB 241, that would create the Renal Disease Council and Renal Disease Council Fund. This task force will study the reasons for the rising incidence of kidney disease in the state and ways to prevent it. The American Kidney Fund (AKF) is the nation’s leading nonprofit organizations working on behalf of the 37 million Americans living with kidney disease, and the millions more at risk, with an unmatched scope of programs that support people wherever they are in their fight against kidney disease, from prevention through transplant. With programs that address early detection, disease management, financial assistance, clinical research, innovation and advocacy, no kidney organization impacts more lives than AKF. We are also one of the nation’s top-rated nonprofits, investing 97 cents of every donated dollar in programs, AKF has also received the highest 4-Star rating from Charity Navigator for 19 consecutive years, as well as the Platinum Seal of Transparency from Guidestar. Kidney disease is the fastest-growing non-contagious disease in the United States, with 14% of the population believed to have chronic kidney disease (CKD).[1] There are no symptoms of CKD in the early stages, but if a person does not receive treatment, CKD will progress to End Stage Renal Disease (ESRD). The only treatment for ESRD is dialysis or transplant, both life-altering and high-cost options. However, if diagnosed in its early stages CKD can often be slowed or stopped with medication, lifestyle, and diet changes. That is why we are so supportive of all efforts, both public and private to educate, prevent, detect, diagnose, and treat this disease. The pandemic has significantly exacerbated the rising rates of kidney disease. In fact, as many as half of the patients with COVID-19 that go into the ICU are now experiencing kidney failure. As a result, the demand for kidney disease treatment, including dialysis will continue to rise even once the pandemic passes. According to Dr. Steven Coca, associate professor of nephrology at Mount Sinai Health System “The next epidemic will be chronic kidney disease in the U.S. among those who recovered from the coronavirus. Since the start of the coronavirus pandemic, we have seen the highest rate of kidney failure in our lifetimes. It’s a long-term health burden for patients, the medical community — and the U.S. economy.” This task force will study the reasons for the rising incidence of kidney disease in the state and ways to prevent it. Even before the current pandemic, rates of kidney disease have been consistently rising across the country. But the current crisis has significantly increased the urgency to develop comprehensive solutions, specifically to address kidney disease. For these reasons, we are hopeful for your support and stand ready to do whatever we can to help this legislation move forward. Thank you again for your time and for your careful consideration of this important issue. If you have any questions, please feel free to contact me directly at any time. Sincerely, Lindsay Gill American Kidney Fund State Policy and Advocacy lgill@kidneyfund.org

Comments Document

Dear Chair Orrock and Vice Chair Head: On behalf of ATA Action, the American Telemedicine Association’s affiliated trade association focused on advocacy, I am writing you to express our support for Senate Bill 369 as it relates to telemedicine. Senate Bill 369 serves as a small but positive step forward for Virginia’s telemedicine policy. The proposed legislation enables physicians licensed and in good standing in other states to provide continuity of care through telemedicine services to Virginia patients with whom the physician has an established practitioner-patient relationship with an initial in-person evaluation within the previous 12 months. ATA Action applauds the legislature for seeking to expand access to telemedicine by permitting out-of-state physicians to provide continuity of care services to established patients. We also take this opportunity to suggest additional licensure flexibilities the Legislature could implement to ensure Virginia patients have access to the high-quality, affordable health care they need. Please consider ATA Action a resource as you consider future telehealth policies.

Requesting information

I do ask elected Virginia officials to improve current Virginia Medicaid. Do change Virginia Medicaid into Virginia Public Option, so that more Virginia residents will get health care. Current Virginia Medicaid has a requirement for low income residents to either work or volunteer 80 hours per month. Do remove these 80 hours per month of working or volunteering permanently to make Virginia Medicaid into Virginia Public Option, so that only low income would qualify a Virginia resident to qualify for Virginia Public Option, but without 80 hours per month of working or volunteering. For example, a Virginia resident has a 401(k), and he or she does not work nor volunteer, but he or she has Virginia Public Option. No person should be required to work or volunteer any number of hours to be able to qualify for a state health care insurance. Working or volunteering any number of hours for a low income person to qualify for a state health insurance is immoral, unethical, and not Christian. Jesus Christ healed and counseled the sick without any conditions such as, if I heal or treat your physical or mental or spiritual issue, you as as my patient has to work or volunteer 80 hours per month to qualify for my healing ministry in my temple sweeping floors, washing statutes, and asking people to take their shoes off their feet before entering a temple of my Father in Heaven, and none of these Jesus asked of His patients, because He helped them unconditionally, so do provide Virginia Public Option to low income Virginia residents without any conditions of working or volunteering.

I SUPPORT SB 201, 241, 436,

Comments Document

On behalf of the Virginia Chapter of the American Academy of Pediatrics, I am writing to express our opposition to SB 672. Specifically, we are concerned with the provision that allows pharmacists, pharmacy technicians, and pharmacy interns to administer all vaccinations to children ages three and up. While we would prefer all children receive vaccines in a medical home setting, we did agree to compromise on the age and had no opposition to House Bill 1323 that was previously passed by this committee. HB 1323 allowed pharmacists to administer vaccines to children ages five and older. We encourage the committee to consider amending SB 672 to increase the age from three to five, as it is in Delegate Orrock’s HB 1323. The reason we believe this is an appropriate age is because children receive an important round of vaccinations at age four, before they are allowed to enter kindergarten. This is a critical window of development prior to school entry for children. It is important children receive their vaccines from a provider who has experience and specialized training in delivering vaccines in a developmentally sensitive manner who can simultaneously provide services like developmental and mental health screenings, counseling about nutrition and injury prevention, chronic disease management, and other important issues that would be identified at a preventive visit. This is also an opportunity for pediatricians to assess social and emotional development to be ready for school, as well as check for medical issues that will need to be addressed by school nurses- including asthma, food allergies, diabetes, and other chronic health issues. For these reasons, we respectfully request the committee amends SB 672 and increases the age to five. Thank you for the opportunity to share our concerns.

RE: SB 672 Dear Mr. Chair and Committee members: I am opposed to SB 672 Section A. Paragraph 11 I have been teaching outpatient lab medicine to medical students, nurse practitioner students, nurse practitioners, physicians in training since 1995 and have seen many things missed by more skilled health care providers. 1. Pharmacists are less trained in this area of medicine. They do not have the time to fill medication, refill medication plus provides vaccinations is well documented by many news articles and personal observations. 2. Diagnosing a strept throat requires a good history and physical exam plus testing if indicated based on evidence-based medicine criteria. If a patient has a sore throat, there are many causes besides strept such as infectious mononucleosis (enlarged spleen in a student athlete can be disastrous) or peritonsillar abscess (which can be life threating if not diagnosed and treated with antibiotics and surgery). Pharmacists do not have adequate training in this area. Regarding pharmacists testing urines for bladder infections (UTI) and kidney infections, We have many concerns. 1. Are they going to collect a fresh clean catch specimen on site or are patients going to bring in an old specimen? Older the specimen and not refrigerated, more likely the specimen will be false positive. 2. If it is male patient are the pharmacists going to do the necessary prostate exam? 3. If a patient has a bad reaction to their treatment, can they access the pharmacist after hours? 4. If the urine specimen is dilated since a patient is drinking lots of fluids can result in a false negative test? 5. Urethritis has similar symptoms as a bladder infection. Many of these patients have a sexually transmitted disease such as chlamydia which does not respond to most typical antibiotics for UTI. 6. I frequently see patients who are dehydrated with urinary burning and bladder spasms/frequency who are not infected but treated for UTIs at urgent care sites. 7. Are pharmacist goings to recognize any other abnormalities on a urine dipstick? Will they miss bladder cancers, kidney cancer or glomerulonephritis? 8. If there is blood on the dipstick, are they going to spin down the urine and look at it under the microscope to confirm it is blood, hemolysis, or myoglobin? Regarding influenza testing, The CDC only recommends treatment for influenzae in high-risk groups, since Tamiflu shortens the illness by less than 24 hours, at significant expense and risk of developing resistant flu strains. Healthy patients are the ones most likely to get tested at a pharmacy and overtreated. From the CDC website: CDC recommends prompt treatment for people who have flu or suspected flu and who are higher risk of serious flu complications. Of course, the pharmacist will not know who is at high risk. There is also a perverse incentive to overtreat, as the pharmacy makes a profit on the drugs used to treat. Pharmacist are overworked and do not need more duties placed on them. Thank you for your support in opposing this bill. Sincerely yours, Roger A. Hofford, M.D. FAAFP, CPE Past President, Virginia Academy of Family Physicians Associate Professor, Family Medicine, Virginia Tech Carilion School of Medicine Clinical Professor, Family Medicine, Virginia College of Osteopathic Medicine Clinical Professor, Family Medicine and Population Health, Virginia Commonwealth University

I am writing to express some concerns regarding SB 672 section A 11, which would allow pharmacists to test and treat for strep throat, influenzae and urinary tract infections. These problems require a history and physical exam to accurately diagnose and treat them-a pharmacist does not have this training. I worry about misdiagnosis with resultant patient harm and overtreatment with antibiotics. These are my specific concerns regarding each CLIA waived test: 1) Only one in 10 sore throats is strep-the majority are caused by viruses. 15% of people are carriers of strep, so 15% of tests will be positive, even with a viral pharyngitis, leading to overtreatment. Using Centor's criteria, a validated clinical decision rule, helps physicians decide who to test-no test is recommended for those without these findings: adenopathy, exudates, fever and those with congestion/cough. Thus, people with a sore throat and URI symptoms (the majority) should not even be tested. Applying this rule on who to test requires a physical exam, which the pharmacists are not trained to do. 2) The CDC only recommends treatment for influenzae in high risk groups, since Tamiflu shortens the illness by less than 24 hours, at significant expense and risk of developing resistant flu strains. Healthy patients are the ones most likely to get tested at a pharmacy and overtreated. The pharmacist will not know who is at high risk without a detailed history. There is also a perverse incentive to overtreat, as the pharmacy makes a profit on the drugs used to treat. 3) Treatment of UTIs based on dipstick urine is the most problematic. Confusing UTI symptoms with urethritis and vaginitis and missing an STD is quite concerning. In patients with a complicated urological history (pyelonephritis, stones, catheters etc. and pregnant patients), a culture should be obtained to assure the correct antibiotic is used and to have sensitivities in the event they get worse and require hospital admission. Again, a good history and physical are required to make the correct diagnosis and prescribe appropriate treatment. 4) There is national concern about pharmacies being overwhelmed with many duties including Covid testing, Covid immunizations and all the other shots they give, in addition to huge volumes of prescriptions. Pharmacies are short of staff and are limiting hours. Burnout from being overworked is a big problem and the risk of errors significant. Here is a link to the New York Times from this week describing the problem: https://www.nytimes.com/2022/02/10/us/politics/pharmacists-strain-covid.html Thanks for considering my comments in deliberating the details of SB 672. I am happy to discuss my concerns further by e-mail or cell phone-804-617-3644. Sincerely, Dr. Bob Newman Clinical Professor Department of Family and Community Medicine Eastern Virginia Medical School