BEFORE THE NEVADA STATE MEDICAL EXAMINERS

 

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                                TRANSCRIPT OF PROCEEDINGS

 

                                 FORMAL BOARD MEETING

 

                               Friday, September 26, 2003

 

                             9670 Gateway Drive, Suite 100

 

                                     Reno, Nevada

 

                                           

 

                                           

 

                                           

 

                                           

 

                                            

 

                                           

 

                                           

 

                                           

 

                                           

 

               

 

              

 

               Reported by:            DENISE PHIPPS, CCR #234, RDR, CRR

 

               

 

 

 


 

 

 

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                                   A P P E A R A N C E S

 

                

 

               

 

                                   BOARD MEMBERS PRESENT

               

               CHERYL A. HUG-ENGLISH - CHAIRWOMAN

               JACQUELINE JONES

               DONALD BAEPLER

               ROBIN TITUS

               SOHAIL ANJUM

               STEPHEN MONTOYA

               JAVAID ANWAR

               

               DRENNAN A. CLARK - Board Counsel

               STEPHEN QUINN -  Deputy General Counsel

               MAUREEN LYONS - Deputy Executive Secretary

                

               

               

              

                                           

              

 

              

 

              

 

              

 

              

 

              

 

              

 

              

 

               

 

              

 

              

 

              

 

 

 


 

 

 

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         1        RENO, NEVADA, FRIDAY, SEPTEMBER 26, 2003, 3:00 P.M.

 

         2                               -o0o-

 

         3                                 

 

         4     1.  Call to Order and Announcements

 

         5    

 

         6                 CHAIRMAN HUG-ENGLISH:  We'll call this

 

         7     meeting of the Nevada State Medical Examiners to order. 

 

         8     I appreciate everybody being available on such short

 

         9     notice.  We have just a few agenda items to cover today. 

 

        10     So hopefully it won't take too long.

 

        11                 It's good to see all of you, sort of, down

 

        12     there.

 

        13                 The first item is we do have a couple of

 

        14     announcements.  And before we get started on those, I

 

        15     would just like to extend good wishes to Marlene Kirsch,

 

        16     who, as most of you are aware by now, fell and broke her

 

        17     hip a couple of days ago.  So we're all sending our best

 

        18     and to let her know we're thinking about her.

 

        19                 And I'll turn it over to Tony.  He has a

 

        20     couple of announcements as well.

 

        21                 MR. CLARK:  Good afternoon.  The first

 

        22     announcement, you may have seen in the newspaper that

 

        23     commencing on October 1st the Board will go through an

 

        24     audit by the Foundation or the Federation of State

 

        25     Medical Boards.  They will be auditing our licensing

 

 

 


 

 

 

                                                                       4

 

         1     procedures, our investigation and disciplinary procedures

 

         2     and our funding procedures.  That's pursuant to

 

         3     legislative directive.

 

         4                 Second, our Deputy General Counsel, Steve

 

         5     Quinn, who is here with us today, will go through some

 

         6     training in Portland, Oregon, October 23rd through

 

         7     October 26, with the Federation of Attorneys on

 

         8     Regulatory Boards.  It's certification training for him

 

         9     to be board counsel.

 

        10                 And third, just a reminder about the one-day

 

        11     seminar put on by the Federation of State Medical Boards,

 

        12     for medical boards and physicians needing assistance or

 

        13     how to deal with the impaired physician.  That's November

 

        14     15th in Las Vegas.  And anyone who wants to attend,

 

        15     please contact Maureen and let her know and she'll make

 

        16     arrangements for it.

 

        17    

 

        18     2.  Consideration of Purchase and Installation of

 

        19         Video-Conferencing Equipment

 

        20    

 

        21                 CHAIRMAN HUG-ENGLISH:  Thanks, Tony.  Our

 

        22     second item is a continuation of a discussion we had at

 

        23     our last Board meeting, and it relates to the purchase

 

        24     and installation of video conferencing equipment.  And,

 

        25     again, Tony has an update for us on that.

 

 

 


 

 

 

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         1                 MR. CLARK:  At the last meeting on September

 

         2     4th, the Board authorized staff to purchase video

 

         3     teleconferencing equipment for the board room in Reno and

 

         4     a place in Las Vegas.  We found out, after the Board

 

         5     meeting, that because it's a relatively large purchase,

 

         6     around $49,000, that we have to go through the State

 

         7     Purchasing Division, the Department of Administration. 

 

         8     And so I sent the two bids that we got down to State

 

         9     Purchasing so that they would know what equipment we

 

        10     required.

 

        11                 They have put it into a bid.  It is out now. 

 

        12     We should have the bids available for opening within

 

        13     three weeks.  As soon as we have a bid approved, we

 

        14     intend to go forward with the purchasing and installation

 

        15     of the equipment in our Reno conference room.

 

        16                 You will recall that at the last meeting, the

 

        17     Clark County Medical Society offered its conference room

 

        18     for video teleconferencing meetings from Las Vegas.

 

        19                 As a result of that invitation, I went down

 

        20     and met with the people at the Clark County Medical

 

        21     Society, and Don Havens and Larry Mathias and Dot and I

 

        22     also went over to the State Board of Dental Examiners

 

        23     office.  They have a conference room as well.  Both

 

        24     conference rooms would meet our requirements.

 

        25                 In both places we could have our meetings on

 

 

 


 

 

 

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         1     Fridays and Saturdays.  They will make the conference

 

         2     room available on Saturdays.  They will have someone

 

         3     there to open the place and to set up the equipment for

 

         4     us.  The State Board of Dental Examiners is very

 

         5     interested in partnering with us so that they would have

 

         6     a place to hold their meetings in Northern Nevada and

 

         7     video teleconference them.  Both places have plenty of

 

         8     parking and are relatively easy to get to.  Both in the

 

         9     southeastern part of Las Vegas.  The Board of Dental

 

        10     Examiners at Tropicana and Eastern, and the Clark County

 

        11     Medical Society on Russell Road, just east of Eastern.

 

        12                 Because it's another state agency, a sister

 

        13     agency that we can assist and can assist us, our

 

        14     recommendation would be that we agree to partner with the

 

        15     State Board of Dental Examiners and utilize their

 

        16     conference room and allow them to utilize ours.

 

        17                 CHAIRMAN HUG-ENGLISH:  Thank you.  I'd like

 

        18     to open it up for discussion from any of the Board

 

        19     members.  Anybody have any comments?

 

        20                 MEMBER ANWAR:  I have a question.  How large

 

        21     is the facility for the dental association?

 

        22                 MR. CLARK:  There is enough room for the

 

        23     entire board and as many people as want to speak, as

 

        24     necessary.  It appears to me to be a good sized room. 

 

        25     It's a little -- it's just a little smaller than our

 

 

 


 

 

 

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         1     conference room in the Reno offices.

 

         2                 MEMBER TITUS:  What days do they meet or how

 

         3     often do they meet?  So there wouldn't be a conflict on

 

         4     our meetings?

 

         5                 MR. CLARK:  They indicated they would be

 

         6     willing to accommodate our meeting schedule.  So that's

 

         7     all I can -- I don't know when they meet specifically.

 

         8                 MEMBER BAEPLER:  Would they accommodate us

 

         9     for Saturday meetings?

 

        10                 MR. CLARK:  Yes, they will.

 

        11                 MEMBER TITUS:  Would they look at then

 

        12     paying, if we buy all of the equipment for the northern

 

        13     office, would they pay for all of the equipment in the

 

        14     southern office?

 

        15                 MR. CLARK:  The initial proposal to them was

 

        16     that we would buy the equipment, both north and south,

 

        17     and they would set it up for us when we're having

 

        18     meetings there.

 

        19                 MEMBER BAEPLER:  How are they set up for

 

        20     amenities for the people we bring in to interview and to

 

        21     spending many hours sitting in the hall?  Is there a

 

        22     convenient place for them to sit and be available?

 

        23                 MR. CLARK:  Yes, there's a convenient waiting

 

        24     room to the outside of the conference room.  And there is

 

        25     a restroom there that's immediately available.  And

 

 

 


 

 

 

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         1     offices that can be used on Saturday when they're not

 

         2     there for any -- for conferences that any individuals

 

         3     might want to have.

 

         4                 CHAIRMAN HUG-ENGLISH:  Any other comments or

 

         5     discussion?

 

         6                 MEMBER TITUS:  It seems -- in my line of

 

         7     business, the only people I know who are retiring early

 

         8     are the dentists.  If we are going to put this equipment

 

         9     into their buildings and fund that equipment for the use

 

        10     of that, their offices, and then they get to use our

 

        11     office at no cost to them, I'm a little bit anxious about

 

        12     the MDs supporting the dentists, for them to then use

 

        13     that when the Medical Society down there have offered it

 

        14     and at least those are physicians.  So I'm a little bit

 

        15     anxious about that particular arrangement and the

 

        16     financial cost to us, and the dentists seem to me they

 

        17     make out like pretty good.

 

        18                 MR. CLARK:  The only thought I have about

 

        19     that is that it's a sister state agency and we'd be

 

        20     assisting them.  And it's a public agency's facility that

 

        21     we would have state equipment in.  So that's the only

 

        22     response that I can make about that.

 

        23                 CHAIRMAN HUG-ENGLISH:  I think in addition to

 

        24     that, if you think about it, we would be assuming the

 

        25     cost either way, at either location.  It was not part of

 

 

 


 

 

 

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         1     the arrangement for the Clark County Medical Society, for

 

         2     example, to pay either.  And so I think the idea is that

 

         3     we had agreed that we were going to provide this

 

         4     equipment to provide greater accessibility to our

 

         5     meetings.  We're looking for a place to do that.  And I

 

         6     think both offers are very generous.

 

         7                 And I do want to again thank the Clark County

 

         8     Medical Society for their generous offer to use their

 

         9     space.  And I think that both offers are good ones, and I

 

        10     think the only -- I think the appealing thought with the

 

        11     dental board is that there is some reciprocity there that

 

        12     would allow, if we're going to put this equipment in,

 

        13     would allow two state agencies to benefit from the use of

 

        14     it.  And so that I see as a side benefit of that

 

        15     combination.

 

        16                 MEMBER BAEPLER:  I have one more question, I

 

        17     assume in Reno we would have one of our staff members

 

        18     trained as a technician to operate the system, what about

 

        19     in Las Vegas?

 

        20                 MR. CLARK:  We would have at least one of the

 

        21     investigators trained to operate the equipment who will

 

        22     come to Las Vegas for the meetings, so that we will have

 

        23     trained personnel at both ends of the state.

 

        24                 MEMBER BAEPLER:  The dental people are going

 

        25     to use it, does that mean every time they want to have a

 

 

 


 

 

 

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         1     meeting we have to send someone down or is it --

 

         2                 MR. CLARK:  No, we wouldn't have to send

 

         3     anyone down to Las Vegas, but we'd have to have one of

 

         4     our people at our Reno office.

 

         5                 MEMBER BAEPLER:  The question still is if

 

         6     it's going to be used by both boards, somebody from the

 

         7     Las Vegas office, presumably the dental group, would have

 

         8     to be trained to operate it.

 

         9                 MR. CLARK:  Correct.

 

        10                 MEMBER BAEPLER:  I think that might be

 

        11     mentioned as part of the agreement.  The alternative is

 

        12     that every time they meet we have to send an investigator

 

        13     down to spend at a meeting with them to operate it.

 

        14                 MR. CLARK:  Yes.  If that was a question, the

 

        15     answer is yes.

 

        16                 MEMBER TITUS:  I just would want to make sure

 

        17     that, don't get me wrong, I think the dentist office

 

        18     offer is a good one also, but I would be leaning towards

 

        19     using the state fellow agency.  I want to make sure if we

 

        20     pay for the cost of this on both ends, which is what we

 

        21     were going to do no matter where we were going to put it,

 

        22     that if the dental board then needs to use it after that,

 

        23     I think any personnel costs, if they're going to use it,

 

        24     should be, we need to make sure it's assumed by the

 

        25     dental people, not us carrying the agency any further.

 

 

 


 

 

 

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         1                 CHAIRMAN HUG-ENGLISH:  My understanding is

 

         2     that we would not be responsible for personnel for their

 

         3     board meetings.  Now, I guess if it's in our office up in

 

         4     Reno, it would make sense that we have an office person

 

         5     available to help out.  But I don't think it would extend

 

         6     to this board sending someone down to Las Vegas to

 

         7     operate the video equipment.  I think that in the

 

         8     purchasing and in the training of that we would make sure

 

         9     that people from both boards were trained how to use it.

 

        10                 Any other thoughts?

 

        11                 MEMBER TITUS:  Is it a motion item?

 

        12                 CHAIRMAN HUG-ENGLISH:  It would be.

 

        13                 MEMBER TITUS:  I would move that we go ahead

 

        14     and go forward with this when the state has done their

 

        15     bidding.  As far as where the location would be, I would

 

        16     propose we have it at the dental office.

 

        17                 CHAIRMAN HUG-ENGLISH:  There is a motion to

 

        18     approve having the video conference placed in the dental

 

        19     board offices in Las Vegas.  Is there a second?

 

        20                 MEMBER JONES:  Second.

 

        21                 CHAIRMAN HUG-ENGLISH:  Any further

 

        22     discussion?

 

        23                 If not, all in favor?  Opposed?  Chair votes

 

        24     in favor of the motion and the motion carries.

 

        25                 So we will go forward then with the bidding

 

 

 


 

 

 

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         1     process through the state and we'll proceed when we have

 

         2     completed that, getting video equipment hooked up in both

 

         3     of those offices.

 

         4                 Any further comments on that.

 

         5                 Tony?

 

         6                 MR. CLARK:  And I will advise the Board, as

 

         7     soon as we have the authority to go forward and what the

 

         8     cost is so all the Board members will know immediately as

 

         9     soon as we know what the cost is.

 

        10                 CHAIRMAN HUG-ENGLISH:  Thank you.  And thank

 

        11     you, Tony, for all the effort.  I know it's been a lot of

 

        12     work in getting those, the prices and the bids and all of

 

        13     that process going.  So I appreciate all the work. 

 

        14     Because it's really moved along quite quickly.  And we,

 

        15     that's our goal with this, to get it up and running as

 

        16     soon as we can.

 

        17    

 

        18     3.  Consideration of Appointment of License Application

 

        19         and Malpractice Review Committee

 

        20    

 

        21                 CHAIRMAN HUG-ENGLISH:  The third item on our

 

        22     agenda is consideration of the appointment of license

 

        23     application and malpractice review committee.  This has

 

        24     been placed on the agenda based on discussions that we

 

        25     had at our last board meeting about the fact that our

 

 

 


 

 

 

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         1     workload has increased dramatically.  The workload not

 

         2     only of the investigative committees, the two committees

 

         3     that we have now, but also the appearances that come

 

         4     before this board.  And so this is a proposal.  And again

 

         5     I'm going to turn it over to Tony to talk a little bit

 

         6     about, but to add an additional committee that might

 

         7     serve a purpose of lightening those appearances for the

 

         8     Board as a whole.

 

         9                 So Tony.

 

        10                 MR. CLARK:  Recall at the last meeting, we

 

        11     had a number of physicians appear who had one or two very

 

        12     small malpractice claims against them.  And they were

 

        13     forced to appear and had good explanations for the claims

 

        14     that were made against them.  It seems a little unfair to

 

        15     the Board and physicians in those situations that they

 

        16     have to come all the way up to Reno to a Board meeting

 

        17     and make an appearance.

 

        18                 So we brainstormed this a little bit and

 

        19     thought that perhaps the three members of the Board who

 

        20     are not on either of the two investigating committees,

 

        21     might form another committee to look at malpractice

 

        22     actions or cases that are $200,000 or less.  The Board

 

        23     would still want to see each of those physicians who has

 

        24     a malpractice claim over 200,000.  But for those under

 

        25     200,000 or 200,000 and less, perhaps they could be

 

 

 


 

 

 

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         1     reviewed summarily by this committee with a determination

 

         2     being made on whether or not that individual had to come

 

         3     before the whole board.  And if not, then the committee

 

         4     would make a recommendation at the next Board meeting

 

         5     that those license requests be granted without a personal

 

         6     appearance by the physician.

 

         7                 And we added into that a review of the

 

         8     respiratory therapists be made by this committee as well. 

 

         9     Because in many instances the Board doesn't need to take

 

        10     up its time with respiratory therapists who don't have

 

        11     significant problems.  In those instances where there's a

 

        12     significant problem, or there's some question about the

 

        13     malpractice response, then those items would be referred

 

        14     by the committee to the whole Board at its next meeting. 

 

        15     Otherwise, the committee would recommend to the Board

 

        16     that it approve all of those applicants for licensure,

 

        17     both respiratory therapists and physicians.  And that's

 

        18     above 200,000 would be before the Board automatically. 

 

        19     Below would be reviewed by the committee.

 

        20                 CHAIRMAN HUG-ENGLISH:  Comments?

 

        21                 We missed that.  Could you repeat?

 

        22                 MEMBER ANJUM:  By that I mean that that

 

        23     physician is being reviewed, he does not have to appear

 

        24     in front of that committee?

 

        25                 MR. CLARK:  No, this would be a records

 

 

 


 

 

 

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         1     review and the review would include all of those

 

         2     explanations submitted by the physician and from the

 

         3     courts and attorneys that we receive in the office, so

 

         4     that there would be a pretty good explanation of the

 

         5     basis for either settlement or the claim or the judgment.

 

         6                 MEMBER ANJUM:  So the physician doesn't have

 

         7     to be there in front of the review committee?

 

         8                 CHAIRMAN HUG-ENGLISH:  That's correct.

 

         9                 MEMBER JONES:  That sounds like a good idea

 

        10     to me.

 

        11                 MR. CLARK:  If I might say it differently. 

 

        12     It's a summary review by the committee as opposed to

 

        13     having an appearance by the doctor.

 

        14                 MEMBER TITUS:  This would actually be done in

 

        15     a timely manner so that if that committee still thinks,

 

        16     man, he's had five of these ,even though they're only

 

        17     $10,000, then you would still have them reviewed.  I know

 

        18     I was one of the ones very frustrated at our last

 

        19     meeting, we had these doctors coming, and I'm just going

 

        20     what are they doing here with our much bigger schedule

 

        21     and the more people we have to look at.  I applaud

 

        22     whoever had this idea, because I think it would be -- I

 

        23     think this is a very forward-thinking idea, and thanks to

 

        24     whoever thought of it.

 

        25                 CHAIRMAN HUG-ENGLISH:  You know, I think that

 

 

 


 

 

 

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         1     we all have felt after the last Board meeting that the

 

         2     number of appearances was rather overwhelming.  And I

 

         3     would like to open it up to make sure that everyone is

 

         4     comfortable with that level of $200,000 to see if that

 

         5     seems to be a level that below which this committee

 

         6     would, the subcommittee would review and above which the

 

         7     Board as a whole would review.  So I'd like some comments

 

         8     on that.

 

         9                 MEMBER ANWAR:  What I'd like to say is that

 

        10     if the committee on review of the records that are there

 

        11     of a particular physician finds the need to visit the

 

        12     physician to ask some further questions clarifying the

 

        13     application and the lawsuits against the physician, then

 

        14     they should have that prerogative to do so.  Otherwise,

 

        15     if they don't deem it necessary, then they don't have to

 

        16     do it that way, then the committee can make

 

        17     recommendations to the full Board.

 

        18                 CHAIRMAN HUG-ENGLISH:  I think the way it

 

        19     would work --

 

        20                 MEMBER MONTOYA:  It's not just necessarily

 

        21     the money, the amount, but somehow we're going to have to

 

        22     also look at what act.  Somebody might have gotten off

 

        23     lucky, just got hit for $200,000, but maybe he did

 

        24     something that really we should know about.  I don't have

 

        25     a mechanism in mind to review those egregious acts, so to

 

 

 


 

 

 

                                                                      17

 

         1     speak.  But seems like we shouldn't set a monetary level. 

 

         2     Maybe something that also protects the public a little

 

         3     bit better.

 

         4                 MEMBER BAEPLER:  I would assume if the

 

         5     committee were looking at the case about MD who had less

 

         6     than 200,000 and thought there were some circumstances to

 

         7     be brought before the whole Board, we'd proceed with a

 

         8     full Board appearance, wouldn't we?

 

         9                 CHAIRMAN HUG-ENGLISH:  Yes, that's correct. 

 

        10     And I think that if there were questions after the three

 

        11     committee members reviewed this, that rather than pulling

 

        12     that individual in before the committee, that person

 

        13     would come before the full Board.  It wouldn't be like an

 

        14     investigative committee meeting where we're meeting and

 

        15     pulling physicians into the subcommittee.  If there are

 

        16     any questions that this committee had, they would be

 

        17     placed on the full Board agenda for the next meeting.

 

        18                 MEMBER TITUS:  One concern I do have about

 

        19     that, as Steve mentioned, is the way some of these

 

        20     hospitals are paying liability and paying costs and so

 

        21     the physician gets off, perhaps.  And so maybe one way we

 

        22     could look at it is a cumulative $200,000 total

 

        23     malpractice suit awards, a death or a single case for

 

        24     200,000.  So there's a couple automatic criteria so you

 

        25     guys aren't wasting your time either.  Because you could

 

 

 


 

 

 

                                                                      18

 

         1     get pretty busy with this, frankly.

 

         2                 MEMBER BAEPLER:  Do you consider adding a

 

         3     third function, a preliminary screening of people that

 

         4     are requesting licensing by endorsement?

 

         5                 CHAIRMAN HUG-ENGLISH:  Can I just comment on

 

         6     that that I think this committee is going to be

 

         7     overwhelmed if we add that in.  I think that --

 

         8                 MEMBER TITUS:  Nice try, Don.

 

         9                 CHAIRMAN HUG-ENGLISH:  I'm a little concerned

 

        10     about adding even the respiratory therapists, quite

 

        11     frankly, to have three people reviewing all of those

 

        12     without the full Board review.  And I think if we add too

 

        13     many things in, I think licensure by endorsement is too

 

        14     new.  It's too big a concept for this Board.  I think it

 

        15     needs full Board attention.

 

        16                 Any other feelings?  Is everybody comfortable

 

        17     then with the monetary cut-off.  If you recall, we used

 

        18     to have $100,000 that would proceed without committee

 

        19     review but would be approved through the regular

 

        20     licensing process.  If it was over $100,000, it would

 

        21     come before the Board for review.  And then since the

 

        22     last legislative session we've been reviewing every

 

        23     malpractice claim as a full Board, no matter if it's

 

        24     $1,000 or 100,000.  So this would be a little higher than

 

        25     what we had as a cutoff.  But recall that with that

 

 

 


 

 

 

                                                                      19

 

         1     cut-off we had no review by any Board members.  This

 

         2     would be a committee looking at it.

 

         3                 So is everybody comfortable with that?

 

         4                 MEMBER ANJUM:  Is there any way to figure out

 

         5     what percent of cases are reviewed that are under 200,000

 

         6     so far?  Is it a 10 percent number or 20 percent or 50

 

         7     percent?

 

         8                 MR. CLARK:  I don't think we've done that

 

         9     kind of a calculation, doctor.  I'm not aware of any.

 

        10                 MEMBER ANJUM:  That might give us an idea how

 

        11     much workload this committee will be and how much

 

        12     workload will be taken off the full Board, really.

 

        13                 CHAIRMAN HUG-ENGLISH:  That's a good point. 

 

        14     I think we can certainly look at that and get some

 

        15     information on that.

 

        16                 MEMBER ANJUM:  Because if it's a large

 

        17     number, we may have to reduce the limit.  Because we

 

        18     don't want to totally overwhelm the new committee and a

 

        19     big workload and some important decisions to be made.

 

        20                 CHAIRMAN HUG-ENGLISH:  Right.

 

        21                 I'm hearing a consensus.  I think that

 

        22     everybody likes this idea; is that correct?

 

        23                 MEMBER ANJUM:  Yes.

 

        24                 MEMBER BAEPLER:  Yes.

 

        25                 CHAIRMAN HUG-ENGLISH:  So maybe what we could

 

 

 


 

 

 

                                                                      20

 

         1     do then is have a motion to approve this committee and,

 

         2     with the level set right now at $200,000, that we could

 

         3     then relook at if it turns out that that's going to be

 

         4     too much or too big a number.  Does that sound

 

         5     reasonable?

 

         6                 MEMBER BAEPLER:  Sure.

 

         7                 CHAIRMAN HUG-ENGLISH:  I need someone to make

 

         8     a motion, please.

 

         9                 MEMBER JONES:  I move that we form this new

 

        10     committee with the three members who are not on the

 

        11     investigative committees.  Do you want the details that

 

        12     they will review the cases that are 200,000 or below

 

        13     200,000, so that they don't have to come before the

 

        14     Board?

 

        15                 CHAIRMAN HUG-ENGLISH:  Yes.  And also it

 

        16     would include the respiratory therapists that don't have

 

        17     significant issues.

 

        18                 So the motion, just to clarify, is to approve

 

        19     the formation of a committee for license application and

 

        20     malpractice review that would review physicians with

 

        21     malpractice claims less than $200,000 and respiratory

 

        22     therapists that do not have significant issues.

 

        23                 Is there a second?

 

        24                 MEMBER ANJUM:  Second.

 

        25                 CHAIRMAN HUG-ENGLISH:  Any further

 

 

 


 

 

 

                                                                      21

 

         1     discussion?

 

         2                 (No response.)

 

         3                 CHAIRMAN HUG-ENGLISH:  If not, all in favor. 

 

         4     Opposed?  The Chair votes in favor of the motion and the

 

         5     motion carries.

 

         6                 So we will proceed in forming that committee. 

 

         7     And we will, I think, activate that committee prior to

 

         8     our December board meeting, and so hopefully that will

 

         9     help with some of the appearances coming up.

 

        10                 MEMBER TITUS:  Could you go over that again?

 

        11                 CHAIRMAN HUG-ENGLISH:  That would be

 

        12     Dr. Jones.  It would be myself and Dr. Anwar.  Welcome. 

 

        13     I think we have some work to do.

 

        14                 So we will, before the next board meeting,

 

        15     we'll convene this committee and we'll see, we'll be able

 

        16     to give the Board some feedback on numbers at the next

 

        17     December board meeting.

 

        18                 MEMBER TITUS:  One concern I do have about it

 

        19     is if somebody is applying for licensure, this committee

 

        20     gets together and decides that there does not need to be

 

        21     an appearance, will it be done in a timely manner so they

 

        22     get enough notice so they can meet at the next board

 

        23     meeting because I would hate to see some of the

 

        24     applications delayed because now it's stuck in this

 

        25     middle committee and so they have to kind of leap frog it

 

 

 


 

 

 

                                                                      22

 

         1     to the following meeting.  So that's an issue.  We don't

 

         2     want to delay people in our state.

 

         3                 MR. CLARK:  The plan is to have this

 

         4     committee meet and have its recommendations formulated in

 

         5     time for that physician, if he or she has to appear at a

 

         6     board meeting, can make the very next board meeting.

 

         7                 CHAIRMAN HUG-ENGLISH:  So we'll make sure

 

         8     that it's done ahead of the 30 days prior to the next

 

         9     board meeting.

 

        10    

 

        11     4.  Consideration of a Second Board Office to be Located

 

        12         in Las Vegas

 

        13    

 

        14                 CHAIRMAN HUG-ENGLISH:  Next agenda item is

 

        15     consideration of a second board office to be located in

 

        16     Las Vegas.

 

        17                 And Tony.

 

        18                 MEMBER BAEPLER:  Madam President, on this

 

        19     particular item I believe technically one would have to

 

        20     move to remove it from the table for consideration, and I

 

        21     would suggest that we not do that, that we need some

 

        22     additional deliberations and consultations and that it

 

        23     ought to be considered at a regularly scheduled meeting

 

        24     of the Board rather than an interim meeting such as this.

 

        25                 CHAIRMAN HUG-ENGLISH:  Is that a motion, Don?

 

 

 


 

 

 

                                                                      23

 

         1                 MEMBER BAEPLER:  No motion is required unless

 

         2     someone moves to take it off the table.

 

         3                 CHAIRMAN HUG-ENGLISH:  We're still tabled. 

 

         4     Any further discussion by other members?

 

         5                 MEMBER TITUS:  Has Tony, have you done work

 

         6     on it that you feel needs to be addressed today.

 

         7                 MR. CLARK:  Not yet.

 

         8                 CHAIRMAN HUG-ENGLISH:  Any opposition to

 

         9     continuing to have that agenda item tabled?

 

        10                 (No response.)

 

        11                 MR. CLARK:  It's tabled to the December

 

        12     meeting.

 

        13                 CHAIRMAN HUG-ENGLISH:  We'll continue to

 

        14     table it until December and bring it up at the next

 

        15     regularly scheduled board meeting.

 

        16    

 

        17     5.  Consideration of Additional Office Space at the Reno

 

        18         Board Office and Associated Costs

 

        19                 

 

        20                 CHAIRMAN HUG-ENGLISH:  Agenda Item 5 is

 

        21     consideration of additional office space at the Reno

 

        22     office and the costs of that.  And Tony is going to tell

 

        23     us about that.

 

        24                 MR. CLARK:  As the Board's business continues

 

        25     to increase, it appears that we are getting cramped in

 

 

 


 

 

 

                                                                      24

 

         1     the Reno offices and need some additional space. 

 

         2     Adjacent to the first floor room that we have in our

 

         3     headquarters building, where the files are now stored is

 

         4     open office, open about equal space, 540 square feet. 

 

         5     The building manager will add that to our lease at a rent

 

         6     of $1.10 a square foot, which is $594 a month.  And

 

         7     utilities of 14 cents a square foot, or 75.60 a month for

 

         8     a total of 669.60 per month.  The idea would be, and we

 

         9     will discuss this with respect to personnel in a moment,

 

        10     but the idea would be that those two offices side by side

 

        11     would be configured to handle our licensing specialists,

 

        12     the files would be moved upstairs to the second floor

 

        13     where the licensing specialists are now.  There is

 

        14     insufficient room to add an additional licensing

 

        15     specialist in the space on the second floor where the

 

        16     four licensing specialists are located now.  And this

 

        17     move downstairs would accommodate an additional licensing

 

        18     specialist.

 

        19                 The building manager will have the carpets in

 

        20     both of the offices where we have both the files now and

 

        21     the empty one cleaned, will paint both offices for us and

 

        22     will cut a double door entry between the two offices in

 

        23     the center wall so that there's immediate access for all

 

        24     of the licensing specialists.

 

        25                 So since we have this opportunity, and space

 

 

 


 

 

 

                                                                      25

 

         1     is a problem, the staff is recommending that you approve

 

         2     that we add this 540 square foot office to our current

 

         3     lease in Reno.

 

         4                 MEMBER TITUS:  How is that affecting our

 

         5     budget?

 

         6                 MR. CLARK:  It would not have any significant

 

         7     effect on the budget as it currently stands.

 

         8                 CHAIRMAN HUG-ENGLISH:  Other comments?

 

         9                 I know it's Friday afternoon, but --

 

        10                 MEMBER BAEPLER:  Sounds like a good idea.

 

        11                 CHAIRMAN HUG-ENGLISH:  I think the issue is

 

        12     that we just really are literally out of space and need

 

        13     to expand into some additional space to continue to

 

        14     function.  And I think we're fortunate that this has

 

        15     opened up at this particular time to allow us to do that. 

 

        16     And I think the cost is reasonable, and I think it makes

 

        17     good sense.

 

        18                 MEMBER TITUS:  I'll so move that we agree to

 

        19     contract for this additional space.

 

        20                 MEMBER JONES:  I'll second it.

 

        21                 CHAIRMAN HUG-ENGLISH:  Okay.  There is a

 

        22     motion and a second to approve the additional office

 

        23     space.  Any further discussion?  All in favor opposed?

 

        24                 The Chair votes in favor of the motion. 

 

        25     Motion carries.

 

 

 


 

 

 

                                                                      26

 

         1     6.  Consideration of Additional Staff Positions

 

         2                

 

         3                 CHAIRMAN HUG-ENGLISH:  In line with that, our

 

         4     next agenda item is consideration of additional staff

 

         5     positions.

 

         6                 MR. CLARK:  You may recall at the last

 

         7     meeting Executive Secretary Larry Lesley told you there

 

         8     was a possibility, and he was looking into the immediate

 

         9     for an additional licensing specialist and an additional

 

        10     investigator.  And he would come back to the Board with a

 

        11     recommendation.  Both of the chiefs, the chief of

 

        12     licensing and the chief of investigations, have indicated

 

        13     that they need an additional person to assist them with

 

        14     their caseloads, an additional licensing specialist and

 

        15     an additional investigator.

 

        16                 If the Board approves the hiring of an

 

        17     additional licensing specialist and an additional

 

        18     investigator, what we plan on doing with the licensing

 

        19     specialist is Casey Miller will be coming back to work. 

 

        20     Recall she's the administrative support person now.  She

 

        21     will be coming back to work from maternity leave on

 

        22     October 1st, or next week.  She would be assigned to the

 

        23     licensing division to be trained as a licensing

 

        24     specialist.

 

        25                 Doug Cooper, the head of investigations, is

 

 

 

 

 

 

 

                                                                      27

 

         1     gathering resumes right now.  If approved for an

 

         2     additional hire, he would start interviews to find a

 

         3     person to fill that position.  So that's where we're

 

         4     starting off with on the request for an additional

 

         5     investigator and an additional licensing specialist.

 

         6                 MEMBER MONTOYA:  Now, if we get these extra

 

         7     two people, we're appointing a new committee to try to

 

         8     reduce the amount of work that the Board has to do up

 

         9     there.  Now, will that be decreasing the number of

 

        10     investigations that are going to have to be carried out?

 

        11                 MR. CLARK:  No, they still have to do the

 

        12     investigations.  And it is based on the investigation for

 

        13     that that this information is compiled and forwarded to

 

        14     the committee to look at.

 

        15                 MEMBER MONTOYA:  It's my supposition, though,

 

        16     that the new committee will say these people do not need

 

        17     further investigations on this new committee.  Now am

 

        18     I -- Madam Chair, am I wrong in my thinking there?

 

        19                 CHAIRMAN HUG-ENGLISH:  The new committee will

 

        20     not be dealing with any investigative issues.  These will

 

        21     be people that are applying for new licenses that are

 

        22     going through the Michigan licensing process.  So it

 

        23     would be under the licensing specialists for sure.  It

 

        24     wouldn't be under the investigator.  These would not be

 

        25     people that are being investigated.  These are people

 

 

 

 

 

 

 

                                                                      28

 

         1     applying for new licenses in the state that this new

 

         2     committee would be dealing with.

 

         3                 And the design of this committee is really to

 

         4     just eliminate the people that the Board would likely

 

         5     automatically grant licenses to based on very simple, you

 

         6     know very small malpractice claims or some other

 

         7     something that was mentioned on their application.

 

         8                 So I don't think that the formation of this

 

         9     committee would affect the hiring of these two people or

 

        10     the workload.

 

        11                 MEMBER BAEPLER:  The role of the investigator

 

        12     will be to take care of the huge caseload out of the

 

        13     court system.

 

        14                 CHAIRMAN HUG-ENGLISH:  Correct.

 

        15                 MEMBER MONTOYA:  The new licensing specialist

 

        16     will be coming under this, more or less will be handling

 

        17     some of the work from this new committee also, which is,

 

        18     which we're trying to reduce the number of licensing

 

        19     specialist's work by trying to administratively handle

 

        20     some of this stuff.

 

        21                 CHAIRMAN HUG-ENGLISH:  No.  We're not really

 

        22     trying to reduce the licensing specialist's work, we're

 

        23     trying to reduce the Board's review of these people and

 

        24     the appearances before the Board as a whole.  But the

 

        25     licensing specialist has to do just as much work on these

 


 

 

 

                                                                      29

 

         1     individuals because that's where we get our information.

 

         2                 MEMBER BAEPLER:  The licensing specialist's

 

         3     work is completed before the committee.

 

         4                 MEMBER ANJUM:  As it increases we'll need

 

         5     more investigators and license specialists, that's what

 

         6     it looks like now.

 

         7                 CHAIRMAN HUG-ENGLISH:  Yeah, that's the

 

         8     issue.  The workload of both of these staff divisions has

 

         9     really increased.  And I think for us to keep up with the

 

        10     workload, and as Dr. Baepler mentioned, I think certainly

 

        11     we had statements made from the investigative committee

 

        12     side as to how much the workload has increased and the

 

        13     backload of cases that we now have to review.

 

        14                 So I think we do need these two additional

 

        15     staff people in place.

 

        16                 MEMBER ANWAR:  What about the budgetary,

 

        17     financial consequences?

 

        18                 MR. CLARK:  The budget is sufficient at this

 

        19     point to take care of any new hires that we're proposing

 

        20     at this point.

 

        21                 MEMBER TITUS:  I move we go ahead and allow

 

        22     the hiring of the new investigator and license

 

        23     specialist.

 

        24                 CHAIRMAN HUG-ENGLISH:  We're going to discuss

 

        25     the third one after.  But we'll go ahead with the motion

 

 

 

 


 

 

 

                                                                      30

 

         1     on these first two.  So the motion was to approve an

 

         2     investigator and a licensing specialist.  And I didn't

 

         3     hear a second.  Was there a second?

 

         4                 MEMBER MONTOYA:  Second.

 

         5                 CHAIRMAN HUG-ENGLISH:  Any further

 

         6     discussion?  All in favor.  Opposed?  Chair votes in

 

         7     favor of the motion.  Motion carries.  So we have now

 

         8     approved the hiring of a new investigator and a licensing

 

         9     specialist.

 

        10                 MEMBER TITUS:  I think that this needs to go

 

        11     out as a kind of a PR thing for this Board in that one of

 

        12     the complaints that the Legislature has placed on us is

 

        13     that the delay in getting physicians to our state.  And I

 

        14     think we are doing everything in our power and everything

 

        15     that we can possibly do fiscally to see to that end. 

 

        16     This goes to that by hiring additional workers.  But that

 

        17     was a complaint, that we didn't have enough people.

 

        18                 CHAIRMAN HUG-ENGLISH:  That's correct.  Tony,

 

        19     do you want to talk about number three?

 

        20                 MR. CLARK:  Many of you know that Maureen

 

        21     Lyons, who has been with the Board for over 13 years,

 

        22     will be leaving at the end of January.  And she is the

 

        23     Deputy Executive Secretary.  So we'll have to replace

 

        24     her.  And the administrative support person, Casey

 

        25     Miller, will be going downstairs on October 1st to train

 

 

 


 

 

 

                                                                      31

 

         1     as a licensing specialist.  So I have talked to a person

 

         2     who would be willing to come on board to replace Maureen

 

         3     and Casey to act as both the executive assistant to the

 

         4     executive secretary, office manager.  The information

 

         5     systems administrator and provide administrative support

 

         6     for any letters and reports that I need typed and for any

 

         7     pleadings that Steve Quinn needs typed.

 

         8                 The lady to whom I have spoken used to work

 

         9     for me in the litigation division of the Attorney

 

        10     General's office.  She has experience as a legal

 

        11     secretary, a legal researcher, head of the tort claims

 

        12     division, and she also worked for a time for the ethics

 

        13     commission, where she set up meetings, set up the Board

 

        14     books for the commissioners, made arrangements for

 

        15     commissioner travel.  And, when the executive director of

 

        16     the commission got in hot water with the administration,

 

        17     was the acting chief executive officer of the ethics

 

        18     commission for about six months.  And so she is willing

 

        19     to come on board for us in an executive position for

 

        20     $53,000 a year.  Understanding that we would be losing

 

        21     Maureen, whose salary is higher than that and Casey

 

        22     transferring, whose salary is less.  But there's about

 

        23     $100,000 of salary there.  We would end up saving money

 

        24     in bringing this young lady on board.

 

        25                 MEMBER MONTOYA:  What about the information

 

 

 


 

 

 

                                                                      32

 

         1     technology portion?

 

         2                 MR. CLARK:  She has a lot of background in

 

         3     computers.  She's going to work with Maureen for two

 

         4     months before Maureen leaves.  So she should be

 

         5     up-to-date on everything.  She knows how to run reports

 

         6     already from the Attorney General's Office.

 

         7                 MEMBER ANWAR:  It seems like she may be an

 

         8     excellent candidate from what we hear as far as her

 

         9     qualifications are concerned.  My only concern or would

 

        10     be that we just have a choice of one person for this

 

        11     extremely important position.

 

        12                 MR. CLARK:  Well, yes, the answer is yes. 

 

        13     They asked me who I would hire and I said I know somebody

 

        14     that can meet all these needs, and so I went and talked

 

        15     to her.  But that's how we got to this point.

 

        16                 CHAIRMAN HUG-ENGLISH:  I think there --

 

        17                 MEMBER MONTOYA:  I can't see any problem.

 

        18                 CHAIRMAN HUG-ENGLISH:  I think the other

 

        19     issue is that because we are under sort of a time line

 

        20     here with Maureen planning to leave in January, that if

 

        21     we were to wait and start interviewing multiple

 

        22     candidates at, say bring candidates in in our December

 

        23     meeting, it really wouldn't allow time for training or

 

        24     cross-training for that person.  I think the nice thing

 

        25     about this particular person is that she would be ready

 

 

 


 

 

 

                                                                      33

 

         1     to come in and spend two or maybe three months with

 

         2     Maureen learning the job and feeling very comfortable

 

         3     before she left.  So I think that's to our advantage to

 

         4     have that cross-training going on.

 

         5                 MEMBER ANJUM:  I think we should go ahead.

 

         6                 CHAIRMAN HUG-ENGLISH:  I think we need a

 

         7     motion to approve that.

 

         8                 MEMBER JONES:  I move that we approve the

 

         9     person that Tony is talking about for the position that

 

        10     Maureen is going to vacate.

 

        11                 MEMBER ANJUM:  I second it.

 

        12                 CHAIRMAN HUG-ENGLISH:  There is a motion and

 

        13     a second to approve, and her name is Lori Munson, as

 

        14     executive assistant.

 

        15                 Any further discussion?

 

        16                 All in favor opposed?  Chair votes in favor

 

        17     of the motion, the motion carries.  So we will hire her

 

        18     as well.  So I think that will make a big difference in

 

        19     our staff going forward.

 

        20                 We are, as you know, growing.  The demands of

 

        21     this Board are growing exponentially, and we really need

 

        22     to keep up with making sure we have adequate staff to

 

        23     deal with it.

 

        24     ///

 

        25     ///

 

 

 


 

 

 

                                                                      34

 

         1     7.  Consideration of Setting of Biennial Registration Fee

 

         2         for Practitioners of Respiratory Care

 

         3    

 

         4                 CHAIRMAN HUG-ENGLISH:  All right.  No. 7,

 

         5     consideration of setting biennial registration fee for

 

         6     practitioners of respiratory care.

 

         7                 Tony.

 

         8                 MR. CLARK:  Respiratory therapists.

 

         9                 MEMBER MONTOYA:  Does that mean there will be

 

        10     a reduction?

 

        11                 Since there's going to be, if we're going to

 

        12     make it biennial, we're thinking about also giving them a

 

        13     reduction in a per year price?

 

        14                 MR. CLARK:  No.  At this point we're

 

        15     recommending that the fees be the same, 100 a year or 200

 

        16     for the biennium.  That is about what it costs us to

 

        17     process them and take care of their records.  As a

 

        18     consequence, we're not suggesting there be either an

 

        19     increase or decrease but that it remain the same.  It

 

        20     would be for the biennium, which is $200, a hundred a

 

        21     year.

 

        22                 CHAIRMAN HUG-ENGLISH:  So the only real

 

        23     change in this is instead of a hundred a year, it's 200

 

        24     every two years.  It's the same amount of money but paid

 

        25     like we do every other licensee.

 

 

 


 

 

 

                                                                      35

 

         1                 MEMBER BAEPLER:  The appropriate motion

 

         2     you're looking for is that we change the licensing from

 

         3     an annual to a biennial license.  The fees remain the

 

         4     same, $100 a year.

 

         5                 MR. CLARK:  I think it's already biennial.

 

         6                 MEMBER BAEPLER:  Then why is it on the

 

         7     agenda?

 

         8                 MEMBER MONTOYA:  I look at fee.

 

         9                 MEMBER ANJUM:  The application is biennial --

 

        10                 MEMBER MONTOYA:  Why can't we give them a

 

        11     break if we're going through the paperwork that we've

 

        12     done every year?  It seems like the paperwork shuffle

 

        13     would be less.

 

        14                 MEMBER BAEPLER:  Is it currently annual

 

        15     registration?

 

        16                 CHAIRMAN HUG-ENGLISH:  No.

 

        17                 MEMBER BAEPLER:  Currently biennial.

 

        18                 CHAIRMAN HUG-ENGLISH:  Currently biennial

 

        19     registration.

 

        20                 MEMBER BAEPLER:  Then I guess I don't know

 

        21     why the agenda item is here.  It doesn't appear that

 

        22     we're changing anything.  What am I missing?

 

        23                 CHAIRMAN HUG-ENGLISH:  I think we're just

 

        24     getting approval to maintain the same fee going forward

 

        25     for the biennium.

 

 

 


 

 

 

                                                                      36

 

         1                 MR. CLARK:  That's exactly right.

 

         2                 CHAIRMAN HUG-ENGLISH:  So, in essence, by

 

         3     approving Agenda Item 7, we're keeping things as they

 

         4     are.  But we need -- I think as we have --

 

         5                 MEMBER MONTOYA:  You've got us lost.

 

         6                 CHAIRMAN HUG-ENGLISH:  As we have in the past

 

         7     had -- this agenda item has come up for physician

 

         8     renewals, we've only had the respiratory therapists for a

 

         9     short time.  So this agenda item is really there to say

 

        10     that we're now approaching the biennium of time and do we

 

        11     want to keep it as it is.  And so it's -- a motion would

 

        12     basically keep the fee the same, $100 per year, $200 per

 

        13     biennium, with no change.

 

        14                 MEMBER BAEPLER:  So moved.

 

        15                 MEMBER MONTOYA:  Second.

 

        16                 CHAIRMAN HUG-ENGLISH:  Okay.  There's a

 

        17     motion and a second to keep the respiratory therapists'

 

        18     fees at $200 a biennium.  Any further discussion?

 

        19                 (No response.)

 

        20                 CHAIRMAN HUG-ENGLISH:  All in favor? 

 

        21     Opposed?  Chair votes in favor.  Motion carries.

 

        22    

 

        23     8.  Matters for Future Agenda

 

        24    

 

        25                 CHAIRMAN HUG-ENGLISH:  All right.  Agenda

 

 

 


 

 

 

                                                                      37

 

         1     Item 8, are there any matters for future agenda?

 

         2                 MEMBER TITUS:  Just a comment since our last

 

         3     meeting on September 10th and 11th.  I went down to

 

         4     Dallas to meet with our federation special committee on

 

         5     maintenance of competency.  It was a very interesting

 

         6     meeting.  Everybody came with a little bit different

 

         7     reason for being there.  And I have to tell you, Nevada

 

         8     was leaps and bounds ahead of where most other committee

 

         9     members were at, in their minds.  So I'll enjoy talking

 

        10     to everybody about that at the next meeting.

 

        11                 Also we did discuss at that meeting license

 

        12     by endorsement and some of the issues that the federation

 

        13     has looked at on that.  So I have some information on

 

        14     that that I think we'll hand out at the next meeting and

 

        15     we can look at that before we see these physicians that

 

        16     maybe it will help us look at that a little bit better.

 

        17                 CHAIRMAN HUG-ENGLISH:  Okay.  Thank you.

 

        18                 At this time I would open it up for any

 

        19     public comment.  Is there any public comment?

 

        20                 (No response.)

 

        21                 CHAIRMAN HUG-ENGLISH:  All right.  Dr. Anwar,

 

        22     did you have something that you wanted to say?

 

        23                 MEMBER ANWAR:  There's no public comment

 

        24     here.

 

        25                 CHAIRMAN HUG-ENGLISH:  Thank you.  All right. 

 

 

 


 

 

 

                                                                      38

 

         1     At this time then we will adjourn and I thank you all for

 

         2     being willing to be here on a Friday afternoon.  We'll

 

         3     see you in December.

 

         4                 (Proceedings concluded at 3:50 p.m.)

 

 

         5                               -o0o-

 

         6     

 

         7    

 

         8    

 

         9    

 

        10    

 

        11    

 

        12    

 

        13    

 

        14    

 

        15    

 

        16    

 

        17    

 

        18    

 

        19    

 

        20    

 

        21    

 

        22    

 

        23    

 

        24    

 

        25    

 

 

 


 

 

 

                                                                      39

 

         1     STATE OF NEVADA,   )

                                  )  ss.

         2     COUNTY OF WASHOE.  )

               

         3    

 

         4               I, DENISE PHIPPS, Certified Court Reporter in

 

         5     and for the County of Washoe, State of Nevada, do hereby

 

         6     certify;

 

         7               That on Friday, September 26, 2003, at the

 

         8     State Contractors Board, 9670 Gateway Drive, Suite 100,

 

         9     Reno, Nevada, I was present and took verbatim stenotype

 

        10     notes of the Hearing entitled herein, and thereafter

 

        11     transcribed the same into typewriting as herein appears;

 

        12               That said hearing was taken in stenotype notes

 

        13     by me, a Certified Court Reporter, and thereafter reduced

 

        14     to typewriting under my direction as herein appears;

 

        15               That the foregoing transcript is a full, true

 

        16     and correct transcription of my stenotype notes of said

 

        17     hearing.

 

        18               Dated at Reno, Nevada, this 29th day of

 

        19     September, 2003.

 

        20     

 

        21                                                               

 

        22                             DENISE PHIPPS, CCR #234, RDR, CRR

 

        23     

 

        24      

 

        25