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Healthcare Districts Healthcare Districts are established in accordance with the Local Hospital District Law, Health and Safety Code Section 32000 et seq. Each district is governed by a 5-member board of directors elected at large, by division or from division by the voters of the district. Each director must be a registered voter residing within the district. In addition to its general powers, a Hospital District has the following specific powers provided by statute: (Numerical references are to sections of the Health and Safety Code) • Establish, maintain, and operate one or more health facilities or health services within or without the district for the benefit of the district and the people served by the district (§32121[j]). • Acquire, maintain and operate ambulances or ambulance service within and without the district (§32121[l]). • Establish a nurses' training school in connection with the hospital (§32124). • Fix and establish such rates of charge that so far as possible will permit the hospital to be operated on a self-supporting basis. Make and enforce all rules, regulations and bylaws necessary for the administration of the hospital (§32125). • Establish, maintain, and operate free clinics, diagnostic and testing centers, health education programs, wellness and prevention programs, rehabilitation, aftercare and any other health care services provider, groups and organizations that are necessary for the maintenance of good physical and mental health in the communities served by the district. (§32121[m]) There are currently eight Hospital Districts within Tulare County of which two are in multiple counties (Kingsburg, North Kern-South Tulare). Fresno is the principal county for Kingsburg and Kern is the principal county for North Kern-South Tulare. The Kaweah Delta Health District Municipal Services Review Background Kaweah Delta Health Care District (KDHCD) is a general medical and surgical hospital located at 400 W. Mineral King Avenue in Visalia, CA. It is accredited by the Joint Commission (JC), the Commission on Accreditation of Rehabilitation Facilities (CARF) and licensed by the California Department of Public Health (CDPH).The KDHD began as the Kaweah Delta Hospital District, formed in March of 1961 by a vote of citizens 1 residing within the District’s original boundaries. The Tulare County Board of Supervisors appointed the first governing board. After the establishment of the District's physical boundaries and years of planning, operation of Kaweah Delta District Hospital commenced July 1, 1963. Originally, the Board of Directors leased the former Visalia Municipal Hospital, a 68-bed facility, and provided basic health care needs to the local community. This building, constructed in 1936, was in use until a new hospital was completed in 1969. The Kaweah Delta Healthcare District, as it is now known, is still in operation at this site and in various other sites throughout the County. Kaweah Delta Health Care District is a political subdivision of the State of California and is governed by an elected board of directors elected by division (in the case of the KDHCD, these divisions are dubbed zones). Written Determinations 1) Growth and Population Projection 1. The KDHCD’s current Sphere of Influence (SOI) was last amended in 1975 (LAFCO Resolution 75-038). The KDHCD boundaries encompass 115,569 acres (180.6 square miles). The City of Visalia, a portion of the City of Farmersville and the unincorporated communities of Goshen, Ivanhoe, Lemon Cove, London, Patterson Tract and West Goshen, are all located within the District’s current boundaries. Based on census block-level data, the District’s population was 114,986 in 2000 and 146,020 in 2010. This represents a 27 % increase in population over the last Census period. 2. According to a survey conducted in 2009 by the American Hospital Association (AHA), KDHCD reported that its emergency room received 103,627 visits, its hospital admitted 20,986 patients and that its physicians performed 4,379 inpatient and 3,083 outpatient surgeries. The hospital’s clinics located throughout the county (including areas not within the District’s SOI) and other outpatient facilities support 449,000 visits annually. The District estimates that approximately 50% of its inpatient admissions consist of patients who reside outside of the District’s jurisdictional boundaries. 3. The KDHCD is not proposing to expand its boundaries but would like to change their SOI to more accurately reflect the vast area it serves. In its response to LAFCO’s request for comments, the District indicates that it regards its primary service area to include 19 zip codes and its secondary service area to include 25 zip codes. The region that the District considers to be its secondary service area includes all of Tulare County, the eastern portion of Kings County and southern portions of Fresno County. 4. The Alta Hospital District (AHD), whose boundaries encompass the city of Dinuba and the entire Cutler-Orosi area, became financially insolvent and filed for bankruptcy some years ago. In accordance with the ultimate 2 structure of the District’s bankruptcy agreement, the AHD does not provide a single service, but must remain a legal tax collecting entity until all debts are repaid. The District additionally continues to have 3 board members, but has not met quorum in several years. With the Alta HD no longer able to meet the health care needs of residents within its boundaries, the KDHCD is likely providing healthcare services to the vast majority of residents within the AHD boundaries. 5. In addition to providing a wide range of health care services to people within and beyond its boundaries, the KDHCD is under contract with the City of Visalia to provide health care services to City employees as part of an Employee Assistance Program. Many city employees reside in areas outside of the county that are served by their own healthcare district or other health care provider. Based on the 2.7% average annual population increase within district boundaries, the vast population outside district bounds that regards the KDHCD as its primary source of healthcare and the various health programs the District extends to companies and other government agencies, it is determined that demand for the various healthcare services offered by the KDHCD will continue to grow well into the future. It should be noted that the aforementioned factors are only some of the drivers of increased demand. Population ethnic and age demographics are also reliable indicators of demand for healthcare services; older populations place a higher demand on healthcare services while some ethnicities suffer higher incidences of certain types of illnesses and diseases. Having large populations of either or both indicate that future demand for healthcare services will increase. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The KDHCD manages 581 licensed beds across four facilities: an acute care hospital, a mental health hospital, a rehabilitation center, and a long-term care facility. The KDHCD hospital has a bed capacity of 474 with a daily average occupancy rate of 72.5%. The KDHCD also has an affiliation with a 119-bed assisted living campus that includes independent living cottages, a large skilled nursing facility, and a 12-bed dementia care unit. 2. As mentioned above, the American Hospital Association (AHA) estimates that the KDHCD’s emergency room received 103,627 visits, its hospital admitted 20,986 patients and that its physicians performed 4,379 inpatient and 3,083 outpatient surgeries. Altogether, all hospital clinics and other outpatient facilities support 449,000 visits annually. 3. The District owns or leases land and buildings in various locations including Visalia, Porterville, Exeter, Lindsay and Woodlake. 3 4. The District has completed a $142 million six-story north expansion project known as the Acequia Wing of the Kaweah Delta Medical Center. The first four floors of the 6-floor expansion are now in use. When the 5th and 6th floors become fully operational, an additional 48 beds of capacity will be added to the District’s current 581 bed capacity, bringing total hospital bed capacity to 629 once the entire expansion area is fully operational. Construction of a new $6 million outpatient dialysis center has been completed and a new $7 million dementia center is expected to be completed in 2012. The dementia center is slated to replace the 12-bed unit currently in use for treatment of dementia patients. 5. The North Expansion project is a 20-year plan to replace the existing hospital with a new facility that meets state seismic safety standards. The project includes more space for Kaweah Delta’s ER, which recently received Level III trauma designation; an expansion to the hospitals ORs and ICU; and a completely renovated and updated post-partum unit. The project also allowed the District to overhaul its cardiovascular program with new cardiac intensive care and telemetry units, four cath labs, an electro physiology cardiology lab, three cardiovascular-surgical suites, and an endovascular suite complete with ZeeGo Philips’ diagnostics and therapeutic system. The plan is expected to be fully implemented by 2030. 6. The District annually allocates $10 million for acquiring new or replacing existing capital equipment. 7. Plans and funding for the remaining 2 floors of the District’s Acequia Wing were recently approved by the District’s Board. The Board has also approved plans and funding for expansion of the District’s ambulatory surgery center and its operating room capacity. Funding has also been secured for improvements to the District’s Mineral King Wing and for construction of the building that houses the District’s Kaweah Delta Graduate Medical Education programs. 8. The KDHCD is in the process of applying for Magnet status; has implemented a hire-right program to better review potential hires for interpersonal and clinical competencies, has an effective service excellence program, and launched a clinical skills lab in the hospital for nurses and physicians to learn how to use new equipment. Kaweah Delta will also be launching a graduate medical education program with support from the University of California Irvine. The District plans to start with family practice and emergency medicine residencies in 2013 and roll out programs in surgery, psychiatry, and OB/GYN by 2015. 9. The District entered into a joint exercise of powers agreement with the City of Visalia. The JPA is known as the Visalia Area Hospital Authority (VAHA) and has the power to exercise jointly only those powers common 4 to both the KDHCD and the City. The primary purpose of the JPA is for the acquisition of land and the construction of infrastructure projects. The JPA has the ability to issue bonds to fund projects. The JPA then leases property to the City for an amount sufficient to pay the principle and interest of bonds issued and the City then subleases the facilities to the KDHCD for an amount equal to the Cities obligation to the JPA. Based on the District’s ability to raise significant capital and its aggressive approach toward implementing capital projects, it is determined that the KDHCD presently has the capacity needed to accommodate current demand of healthcare services and has taken adequate steps to ensure that expected demand is accommodated well into the future. It is further determined that the District’s investment in technology, professional development support and efforts to attract high quality medical personnel ensure that demand for a wide array of healthcare service is met, , such as the new dementia center that reflects an aging population, and that services provided are of the highest quality and efficiency. 3) Financial Ability of the Agency to Provide Services 1. For FY 2010/2011 the KDHCD projects net revenue from patient services to be $405,274,000 and projects its net operating revenue (items like non- patient food sales, Lifestyles Fitness Center membership fees, etc.) to total $435,077,000. Operating expenses, which include items like payroll, employee benefits, supplies, services and fees to the District are expected to total $437,707,000. The District’s net revenues and expenses give the District a positive operating margin of $5,070,000. For FY 2010/2011, investment income is projected at $2,770,000 and the District’s excess margin is projected to be $7,840,000. 2. Some of the surplus will be spent to pay the principal amount of debt (such as bonds), self insurance trust, general capital contingency fund, enterprise capital and the annual $10 million set aside for acquisition/construction of infrastructure. Items like the First 5 Grant and amortization/depreciation will offset some of those expenses. Once all of this is accounted for the KDHCD projects $11,232,00 in surplus funds for FY 2007/2008. (Exhibit C: Complete 2007/08 Annual Budget) 3. The District sets its rates according to the revenue necessary to sustain operations, provide for new and replacement capital equipment, payment of debt, maintain strong levels of liquidity and access to capital markets while being mindful of cost of care to the patient. A list of all services offered by the KDHCD and its fees for each would require hundreds of pages of print. It is available upon request. 4. The KDHCD is highly dependent on reimbursement agreements with Medi- Cal and Medicare programs and is subject to regulations set by various State and Federal regulatory, permitting and accrediting agencies. This stringent 5 regulation also applies to the adequacy of facilities. Facility inadequacies could lead to decertification by State and Federal agencies as well as loss of reimbursement for services. Periodic reviews are conducted by the various agencies. The material available indicates that the KDHCD remains in good standing with all regulatory entities and continues to receive funds in accordance with reimbursement agreements suggesting that KDHCD public facilities are adequate. 5. The KDHCD derives less than one-half of one percent of its operating budget from local taxes. The remainder of its budget is raised from patient charges. The KDHCD listed the following items as the primary sources of funds for the District. • Funds Collected for services rendered to patients • Property Tax Revenue • Cafeteria Revenue • Management Services Revenue • Grants • Philanthropy 6. The robust projected amount of surplus funds derived after all expenses and fees have been accounted for and the fact that much of that amount will be reinvested to expand capacity, replace equipment and generally make sure the KDHCD meets all regulations and codes indicates that the District is in stable financial condition and is able to provide health care services well into the foreseeable future. (Exhibit D: 10-Year Financial Forecast) 7. Planning and fundraising for the relative to the acquisition of daVinci Robatic Surgical technology which is now in active use by urologists and OB/GYN physicians operating at the District’s facilities. 4) Status of, and Opportunities for, Shared Facilities 1. As previously mentioned the District leases or owns land/buildings in several locations through out the County. 2. The District is also part of a second JPA that includes the Sierra View District Hospital District and the Tulare District Hospital District and was intended for the purpose of sharing services and/or joint purchasing. Since its formation the JPA has not been utilized. It is determined that the District is already exercising the most logical and feasible opportunities for shared facilities. As previously mentioned; however, the financial insolvency of the Alta Hospital District (AHD) has in all likelihood made the KDHCD the service provider of choice for AHD residents. Accordingly, the District may consider acquiring and upgrading AHD facilities or purchase land for the eventual construction of 6 new facilities in order to better serve AHD area residents and capture some of the patient services revenue that would otherwise go to Fresno County medical facilities. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies Accountability for Community Services 1. The KDHCD’s productivity and overall performance is monitored by various Local, State and Federal agencies. Regulation includes: accreditation from the Joint Commission on Accreditation of Healthcare Organizations; certification from the Medicare and Medi-Cal programs; permits for building, conditional use, expansion, renovation or replacement of major equipment form the Office of Statewide Health Planning and Development, the City of Visalia and from the San Joaquin Valley Air Pollution Control District; licensure from the State Department of Public Health Services; and must register its vehicles with the DMV. 2. The State Department of Public Health levies penalties on hospitals for administrative violations that jeopardize the health or safety of a patient (e.g. botched surgeries and disabilities associated with medication error) and for breach of a patient’s confidential medical information. Penalties can be as high as $100,000 per violation. The list of hospitals cited is published each year on the State Department of Public Health’s website. The KDHCD does not appear on the list for 2010. 3. The KDHCD makes available various publications to inform the public of its services, activities and accomplishments. The KDHCD also engages in health screenings and health education. 4. Operational benchmarks are set continually, both agency-wide and by department, and compared against other similar organizations throughout the country to ensure efficient operations and provide contacts for best practices utilized by others. 5. As detailed in the background portion of this MSR, in accordance Government Code 56430 LAFCO is required to conduct a Municipal Service Review and make determinations. The KDHCD has complied with this local governance mechanism by providing detailed answers to LAFCO’s MSR Questionnaire, a detailed organizational chart and detailed financial documents including a 10-year forecast of various financial items. 6. The Tulare County Grand Jury conducted an investigation into whither area hospitals are fulfilling the requirements set by the Emergency Medical Treatment and Labor Act (EMTALA), Section 1867 of the Social Security Act. The act proposes to protect those seeking emergency treatment from 7 hospitals transferring, discharging, or refusing to treat patients coming to hospital emergency rooms. These practices are commonly referred to as “dumping”. The act applies to Medicare participating hospitals but protects all patients, not just Medicare beneficiaries. A detailed list of the EMTALA requirements is attached to this MSR. The investigation was prompted by the extensive media coverage regarding physician/surgeon shortages in Tulare County. The Grand Jury investigation focused on hospital emergency service and scheduling of surgical personal. Procedures followed: • Visited all areas hospitals • Interviewed relevant witnesses • Reviewed relevant documents Findings of relevance: • The KDHCD has established its own procedures to make sure that emergency personal is available 24 hours per day, 7 days per week and 365 days per year. • The KDHCD has on-call lists and schedules in place with nursing supervisors, trained in emergency procedures, who will call a physician/surgeon who then assembles a team to deal with the emergency. The process may take over an hour. • The KDHCD treats approximately 78,000 emergency patients each year (the hospitals own records, cited above, give a lower estimate). • KDHCD has put in place an incentive fee schedule designed to attract local physician/surgeons for unscheduled medical duty. • The Kaweah Delta, Tulare District and Sierra View hospitals can call on each other to help in times of shortages. Governmental Structure and Operational Efficiencies 1. The KDHCD Board of Directors is comprised of 5 members who are registered voters and reside within the District. The KDHCD boundaries are divided into five zones and each board member represents a specific zone. 2. Regular Board meetings are held on the second Monday of each month. Meeting agendas are posted in the hospital and are also faxed and emailed to the Visalia Times-Delta, the Fresno Bee and the Valley Voice newspapers. Agendas are also posted on the District’s webpage: www.kaweahdelta.org. 8 3. The KDHCD has over 3,500 full-time and part-time employees. Full-Time Employees • 8 executive positions • 153 management positions • 1,164 professional positions • 1,011 operational positions Part-Time Employees • 4 management positions • 397 professional positions • 155 operational employees The KDHCD also employs 140 professional employees who provide their services to the District under contractual agreements. The KDHCD operates within a highly regulated industry. It is determined that the sheer number of regulatory and permitting agencies the KDHCD must report to, along with the rigor of oversight, ensure adequate accountability for the provision of healthcare services by the District. It is also determined that the District’s governmental structure and staff levels provide for quality and efficient provision of service as well as open and transparent government. The health care industry as a whole is being compelled to be more transparent, with quality and efficiency measures becoming much more publicly available. Based on the data cited above, that the KDHCD falls in line with this positive trend. Some of the challenges that management faces on an ongoing basis are: manpower shortages in areas like nursing and numerous technical and professional fields. Providing healthcare services to uninsured and underinsured patients while remaining financially viable and the rapidly changing demographics of the community are a challenges that must be met head-on, only for reasons of compassion and quality of life, but also because of the economic consequences that accompany inaction. 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Commission Policy Recommendations: The original draft of this MSR, submitted to the Commission on June 1, 2011, contained the following recommendation: It is recommended that the District’s SOI be expanded to include the additional area it likely serves, in particular, the area once served by the Alta Hospital District. Inclusion 9 of the area into the District’s SOI could also be accompanied by annexation of the area into the District’s jurisdictional boundaries. Dissolution of the Alta Hospital District will need to take place first. Since the original MSR was submitted to the Commission, LAFCO Staff has prepared a summary of Alta Hospital District operations since it filed for bankruptcy protection. The District continues to receive property taxes for the purpose of repaying debt obligations as directed by the Federal Bankruptcy Court. District officials indicated that once all debt obligations have been met, the District may still continue to provide services allowed under the Healthcare District Law. If this is the course the District takes after the bankruptcy plan is fully effected, the District will most likely maintain its existing SOI, making inclusion of the area into an expanded Kaweah Delta HD SOI impossible; CKH prohibits overlapping SOI boundaries. The KDHD, in its reply to LAFCO’s request for comment, requested that its SOI be expanded to include all of Tulare County, since it provides services to individuals from the entire region. This; however, is impossible to accommodate because such a request would naturally cause an overlap of all county healthcare district SOIs. Accordingly, it is now recommended that the KDHD SOI be expanded as much as possible without causing an overlap with other healthcare district SOIs in order to reflect a much more accurate service area for the District, to the largest degree possible. 10 Tulare Local Health Care District Municipal Services Review Background The Tulare Local Health Care District (TLHD) operates a general acute care hospital located at 869 Cherry Avenue in Tulare, CA. It is accredited by the Joint Commission (JC), DNV, Healthcare, Inc., College of American Pathologists (CAP) and the Commission on Accreditation of Rehabilitation Facilities (CARF). In January 1946, voters within the District’s original boundaries passed two consecutive bond measures and with Federal government aid the Tulare Local Health Care District was formed. The original Board of Directors was appointed by the County Board of Supervisors. Construction of a new $1.1 million, 86-bed hospital began on May 23, 1949 and was completed on February 18, 1951. In December of 1989 the hospital broke ground on the $12 million front expansion and renovation project. This project was completed in 1993 and included remodeled patient rooms, lobby, expanded ICU and new pediatric unit. In 1998 the TLHD purchased an x-ray center to expand medical imaging services and in 2005 the hospital opened Evolutions Fitness and Wellness Center and began outpatient rehabilitation services with a stated mission to support and encourage wellness behaviors in the community. In 2009 the District began operating and doing business under the name of Tulare Regional Medical Center (TRMC). That same year, the TRMC opened three Rural Health Clinics that provide access to primary and specialty medical care. Currently, TRMC operates the Hillman Healthcare Center, Kingsburg Healthcare Center, Lindsay Healthcare Center, and Woodville Healthcare Center. Plans are currently underway to open a fifth Rural Health Clinic in Earlimart. These clinics provide services to nearly 42,000 patients each year. Tulare Regional Medical Center is also licensed to provide clinical services through a Mobile Unit in Alpaugh, and Pixley. In May of 2010 TRMC broke ground on a 115,000 square foot expansion project and Medical Tower. More than 83% of the District’s Voters approved an $85 million General Obligation bond to help fund the Medical Tower expansion. The TLHD is a political subdivision of the State of California, recognized under the California Local health Care District Law and is governed by a 5-member elected Board of Directors Written Determinations 1) Growth and Population Projection 1. The TLHD’s current Sphere of Influence (SOI) was last amended on August 20, 1975 (LAFCO Resolution 75-038). The TLHD boundaries encompass 63,509 acres (430.4 square miles). The City of Tulare and the unincorporated communities of Tipton, Pixley and several other Census Designated Places (CDP), are all located within the District’s current 1 boundaries. Based on census block-level data, the District’s population was 63,509 in 2000 and 80,649 in 2010. This represents a 27% increase in population over the last Census period. 2. According to a survey conducted in 2009 by the American Hospital Association (AHA), TLHD reported that its emergency room received 32,493 visits, its hospital admitted 5,736 patients and that its physicians performed 1,216 inpatient and 2,160 outpatient surgeries and 1,226 births. The hospital’s clinics located throughout the county (including areas not within the District’s SOI) and other outpatient facilities support 74,493 total visits each year. Based on the District’s healthy 27% population growth rate experienced over the last 10 years, steady increase in the need for added capacity over the District’s 62-year existence (from 86 beds in 1949 to its current 112-bed capacity), the limited population outside district bounds that regards the TLHD as its primary healthcare provider, it is expected that demand for the various healthcare services offered by the TLHD will increase at a steady rate, a sharp increase in demand for District services is not expected. Population growth rate; however, is only one driver of increased demand for medical services. The ethnic and age demographics of a given population are also reliable indicators of the demand for healthcare services; older populations place a higher demand on healthcare services while some ethnicities suffer higher incidences of certain types of illnesses and diseases. Having large populations of either or both indicate that future demand for healthcare services will increase. According to the 2010 Census, Tulare County’s population is 60% Hispanic and 9.4% of the County’s population is 65 year of age or older, a small but significant proportion. These two groups are vulnerable/high-risk populations for certain illnesses such as diabetes and other cardiovascular conditions. Due to recent changes in administrative leadership and a regional approach to healthcare delivery and added Rural Health Clinics, TRMC has experienced an increase in patient volume. The District has conducted recruitment of a new Emergency Department Physician Group, Radiology Group and Anesthesiology Team in 2009 in an attempt to increase the quality and range of care and service provided in the District. The District has also investment in state-of-the-art technology to further improve the quality and range of service, also in attempt to serve a wider group and more diverse group of healthcare patients. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The TLHD manages 112 licensed beds. 2. As mentioned above, the American Hospital Association (AHA) estimates that in 2009 the TLHD emergency room received 32,493 visits, its hospital admitted 5,736 patients and that its physicians performed 1,216 inpatient and 2,160 outpatient surgeries. Altogether, all hospital clinics and other outpatient facilities support 74,493 visits annually. 2 3. The District owns or leases land and buildings in Tulare, Lindsay and the community of Woodville as well as Kingsburg, just outside of Tulare County. 4. In 2005, voters approved Measure D, an $85 million bond for the construction of 115,000 square foot Medical Tower expansion on the hospital’s main campus. Construction began in May 2010 and is expected to be completed in 2012. The expansion will include 26-bed emergency department (a 400% increase in emergency department capacity), five new surgery suites-including robotic capabilites, 16 private birthing rooms, a new nursery and NICU, 27 private medical surgical rooms and a state-of-the-art imaging center. 5. In February of 2011, the TRMC opened its most recent rural clinic, the Woodville Healthcare Center. The center offers approximately 1,700 residents of the isolated rural community basic healthcare services such as flu shots and will soon have an OB-GYN on staff. The clinic also offers bilingual staff. TRMC officials estimate that the Woodville Healthcare Center will serve about 1,200 patients each month. The project cost approximately $230,000. 6. In accordance with a federal health care program, most U.S. hospitals now survey recently discharged patients regarding their stay. TRMC patients were asked whether they would recommend the hospital to friends and family. 62% of respondents said they would definitely recommend TRMC; the statewide average is 67%. Based on the District’s ability to raise adequate capital to fund infrastructure projects, modest customer base and steady population growth rate within district boundaries, it is determined that the District presently has the capacity needed to accommodate current demand of healthcare services and has taken adequate steps to ensure that expected demand is accommodated in the future. The District is pursuing technology upgrades, professional development support and efforts to attract high quality medical personnel to ensure that demand for a wide array of healthcare service is met in the future. It should be noted that the hospital’s service area is a Primary Care Health Profession Shortage Area (MUA) and serves a Medically Underserved Population (MUP). The District’s new Woodville Healthcare Clinic illustrates that district management is in tune with the needs of district residents and implements solutions intended to the healthcare challenges faced by primarily rural areas. 3) Financial Ability of the Agency to Provide Services 1. The most recent budget information that could be independently located for the District is from FY 2007-2008. For FY 2007-2008, the TLHD reported $73,214,370 in revenues, $71,431,808 in expenditures and $34,367,984 in debt. This indicates that the District was operating at a profit margin. In 2008, a new CEO was appointed in an attempt to change the Districts business model. 3 According the District’s 2010 Annual Report, there have been marginal increases in patient volume and a subsequent increase in patient service revenues. The District’s operating margin has also increased. 2. 71% of hospital patients are on Medicaid or Medicare, making the TLHD highly dependent on reimbursement agreements with Medi-Cal and Medicare programs and making it subject to regulations set by various State and Federal regulatory, permitting and accrediting agencies. This stringent regulation also applies to the adequacy of facilities. Facility inadequacies could lead to decertification by State and Federal agencies as well as loss of reimbursement for services. Periodic reviews are conducted by the various agencies. The material available indicates that the TLHD remains in good standing with all regulatory entities and continues to receive funds in accordance with reimbursement agreements suggesting that TLHD public facilities are adequate. 3. The District is an early adopter of electronic medical records and as such, stands to receive $1,000,000 in federal stimulus funds. 4. The TLHD derives less than one-half of one percent of its operating budget from local taxes. The remainder of its budget is raised from patient charges. The TLHD listed the following items as the primary sources of funds for the District. • Funds Collected for services rendered to patients • Property Tax Revenue • Cafeteria Revenue • Management Services Revenue • Grants • Philanthropy Although the District’s financial performance prior to 2008 was poor (according to a 2010 California Healthcare Foundation report, the District was projected to incur $2,000,000 more in expenditures and than revenues generated for FY 2007-2008), the District’s financial performance has been steadily strengthening. So long as the District’s goal of becoming a large, multi-service healthcare provider results in a greater market share of the region, the District will be able to meet service demand with quality service in the future due to the increased revenues that come with such an approach. 4) Status of, and Opportunities for, Shared Facilities 1. As previously mentioned, the District owns facilities throughout the County in order to provide healthcare service to isolated rural communities. 2. The District was chosen in March 2010 by the Kingsburg Healthcare District to act as a conservator for its hospital license through a management agreement to maintain the medical services and care to the Kingsburg 4 community members through the continued operation of a Rural Health Care Clinic. (The Kingsburg District’s emergency room and acute care operations were closed in 2008 and its skilled Nursing facility was closed in January 2010.) 3. The District forms part of a JPA that includes Sierra View District Hospital District and Kaweah Delta Healthcare District, which was intended for the purpose of sharing services and/or joint purchasing. Since its formation the JPA has not been utilized. It is determined that the District is already exercising the most logical and feasible opportunities for shared facilities. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies 1. The TLHD’s productivity and overall performance is monitored by various Local, State and Federal agencies. Regulation includes: accreditation from the Joint Commission on Accreditation of Healthcare Organizations; certification from the Medicare and Medi-Cal programs; permits for building, conditional use, expansion, renovation or replacement of major equipment form the Office of Statewide Health Planning and Development, the City of Tulare and from the San Joaquin Valley Air Pollution Control District; licensure from the State Department of Public Health Services; and must register its vehicles with the DMV. 2. The State Department of Public Health levies penalties on hospitals for administrative violations that jeopardize the health or safety of a patient (e.g. botched surgeries and disabilities associated with medication error) and for breach of a patient’s confidential medical information. Penalties can be as high as $100,000 per violation. The list of hospitals cited is published each year on the State Department of Public Health’s website. The TLHD does not appear on the list for 2010. 3. The TLHD makes available various publications to inform the public of its services, activities and accomplishments. 4. Operational benchmarks are set continually, both agency-wide and by department, and compared against other similar organizations throughout the country to ensure efficient operations and provide contacts for best practices utilized by others. 5. As detailed in the background portion of this MSR, in accordance Government Code 56430 LAFCO is required to conduct a Municipal Service Review and make determinations. LAFCO made three separate 5 requests for information form the District, none of which were answered. However, it was determined the request for information was addressed to an individual no longer employed by the District. 6. The Tulare County Grand Jury conducted an investigation into whether area hospitals are fulfilling the requirements set by the Emergency Medical Treatment and Labor Act (EMTALA), Section 1867 of the Social Security Act. The Act proposes to protect those seeking emergency treatment from hospitals transferring, discharging, or refusing to treat patients coming to hospital emergency rooms. These practices are commonly referred to as “dumping”. The Act applies to Medicare participating hospitals but protects all patients, not just Medicare beneficiaries. A detailed list of the EMTALA requirements is attached to this MSR. The investigation was prompted by the extensive media coverage regarding physician/surgeon shortages in Tulare County. The Grand Jury investigation focused on hospital emergency service and scheduling of surgical personal. Procedures followed: • Visited all areas hospitals • Interviewed relevant witnesses • Reviewed relevant documents Findings of relevance: • The TLHD has established its own procedures to make sure that emergency personal is available 24 hours per day, 7 days per week and 365 days per year. • The TLHD has on-call lists and schedules in place with nursing supervisors, trained in emergency procedures, who will call a physician/surgeon who then assembles a team to deal with the emergency. The process may take over an hour. • The TLHD treats approximately 50,000 emergency patients each year (the hospitals own records, cited above, give a lower estimate). • TLHD has put in place an incentive fee schedule designed to attract local physician/surgeons for unscheduled medical duty. • The Kaweah Delta, Tulare Regional and Sierra View hospitals can call on each other to help in times of shortages. Governmental Structure and Operational Efficiencies 6 1. The TLHD Board of Directors is comprised of 5 members who are registered voters and reside within the District. District board members are elected at large and do not represent specified zones, districts or regions. 2. Regular Board meetings are held on the fourth Wednesday of each month at 4:00 PM. Meeting agendas are posted in the hospital, posted on their website and are also faxed and emailed to the Visalia Times-Delta, the Fresno Bee and the Valley Voice newspapers. 3. Tulare Regional Medical Center employs approximately 700 full-time and part-time employees. The TLHD operates within a highly regulated industry. It is determined that the sheer number of regulatory and permitting agencies the TLHD must report to, along with the rigor of oversight, ensure adequate accountability for the provision of healthcare services by the District. It is also determined that the District’s governmental structure and staff levels provide for quality and efficient provision of service as well as open and transparent government. Some of the challenges that management faces on an ongoing basis are: manpower shortages in areas like nursing and numerous technical and professional fields. TRMC has addressed the need for ongoing staff training and support in technical and professional areas of healthcare operations through partnerships with staffing companies leading their field of healthcare expertise. Providing healthcare services to uninsured and underinsured patients while remaining financially viable and the rapidly changing demographics of the community are challenges that must be met head-on, only for reasons of compassion and quality of life, but also because of the economic consequences that accompany inaction. 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Commission Policy Recommendations: It is recommended that the District pursue joint purchasing ventures of supplies and equipment whenever feasible through use of the JPA comprised of area hospitals. 7 Sierra View Local Health Care District (SVLHCD), Sierra View District Hospital (SVDH) Municipal Services Review Background The Sierra View Local Health Care District (SVLHCD) was formed by resolution of the Tulare County Board of Supervisors on October 21, 1947. In February 1957, hospital construction began and was completed one year later. The new 42-bed hospital opened its doors on March 1, 1958. For nearly 30 years, the hospital remained virtually unchanged until a three-story patient tower was added in 1985. The past 20 years have seen significant growth. In 1990 a new Cancer Treatment Center was added to the campus. 1995 marked a major expansion for the hospital as the four-story patient tower with full basement opened. In 2003, Sierra View opened its Medical Office Building (MOB) on Pearson Drive just north of the main campus. This building houses hospital outpatient services along with office space for support staff. In 2005 the Cancer Treatment Center completed a ten thousand square feet extensive expansion and remodeling project that saw the facility nearly double in size. Most recently, Sierra View completed its new outpatient Dialysis Center located just north of the MOB. Recent enhancements include the addition of a new state of the art MRI and CT scan, an expanded full service Cancer Care facility and a seven-bed pediatric unit operated in collaboration with Children’s Hospital of Central California. The SVLHCD is a political subdivision of the State of California and is governed by an elected Board of Directors Written Determinations 1) Growth and Population Projection 1. The SVLHCD’s current Sphere of Influence (SOI) was last amended on August 20, 1975 (LAFCO Resolution 75-038) and contains an area of 1,389,970 acres (2,172 square miles). The SVLHCD boundaries are coterminous with its SOI. The City of Porterville and the unincorporated communities of Strathmore, Ducor, Terra Bella, Springville, California Hot Springs, Porterville, Poplar and Plainview as well as several Census Designated Places (CDP) are all located within the District’s current boundaries. Based on census block-level data, the District’s population was 80,142 in 2000 and 92398 in 2010. This represents a 15% increase in population over the last Census period. 2. According to a survey conducted in 2009 by the American Hospital Association (AHA), SVLHD reported that its emergency room received 44,131 visits, with 7,948 patients admitted and that its physicians performed 1,940 inpatient and 2,839 outpatient surgeries and 2,004 births. The hospital’s clinics and other outpatient facilities support 166,117 total visits each year. The SVLHCD owns and leases two facilities located outside its main campus; one on Kessing Street and at the MOB on North Pearson Drive. 3. Fitch Ratings, a global ratings agency that provides bond ratings through prospective and independent credit opinions, research and data, conducted an analysis of bonds issued to fund the District’s West Wing Expansion Project (discussed below). According to their research, the SVLHCD has a 60% market share within its service area (i.e. within its district boundaries. This indicates that approximately 40% of healthcare customers choose another healthcare provider, either within the county or out of the region, for healthcare services. 4. SVLHCD does not plan to expand their jurisdictional boundaries or their SOI. Based on the District’s healthy 1.5 % population growth rate experienced over the last 10 years, steady increase in the need for added capacity over the District’s 53-year existence, the limited population outside district bounds that regards the SVLHD as its primary healthcare provider and its low patient volume, it is determined that demand for the healthcare services offered by the SVLHCD will increase at a steady rate, a sharp increase in demand for District services is not expected. Population increase; however, is only one driver of increased demand for medical services. The ethnic and age demographics of a given population are also reliable indicators of demand for healthcare services; older populations place a higher demand on healthcare services while some ethnicities suffer higher incidences of certain types of illnesses and diseases. Having large populations of either or both indicate that future demand for healthcare services will increase. According to the 2010 Census, Tulare County’s population is 60% Hispanic and 9.4% of the County’s population is 65 years of age or older, a small but significant proportion. These two groups are vulnerable/high-risk populations for certain illnesses such as diabetes and other cardiovascular conditions. The SVLHCD must invest in technology and professional development geared toward procedures that are likely to be in high demand based on the District’s population demographics, which the District has done by building a 32 Station Outpatient Dialysis Center. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The SVLHCD is a163–bed general acute care hospital licensed by the Cailfornia Department of Public Health. 2. As mentioned above, the American Hospital Association (AHA) estimates that in 2009 the SVLHCD emergency room received 44,131 visits, its hospital admitted 7,948 patients and that its physicians performed 1,940 inpatient and 2,839 outpatient surgeries. Total, the District accommodates 166,117 outpatient visits. Unlike the other two major hospitals in the region, the SVLHCD does not own or lease any facilities outside of its main campus. 3. In 2007, the District opened a 32-station outpatient dialysis center. 4. The District’s Master Plan and Hospital Expansion Project proposed a 125,000 square foot 4-story west wing addition that is intended to replace hospital visits currently housed in the original hospital building, increase the hospital’s acute bed capacity from 85 to 170, expand hospital services and meet new state seismic safety regulations. Construction was expected to begin in 2009 and the District has already issued approximately $54 million dollars in bonds; however, in late 2008 the District was notified by the state that, under revised criteria, the Districts hospital facility was seismically complaint for use through the year 2030. As a result, the project was postponed and the District is in the process of reevaluating its master facility plan in light of this development. 5. In accordance with a federal program, most U.S. hospitals now survey recently discharged patients regarding their stay. SVLHCD patients were asked whether they would recommend the hospital to friends and family. Only 44% of respondents said definitely compared to the state average of 67% and national average of 68%. 6. In order to ensure that the District can rely on adequate staff levels, it implemented the Salary Stipend 20/20 Program, which allowed eligible full-time nurse employees to work half-time (20 hours per week) and attend school, while the District continued to pay their full-time salary. According to a California Healthcare Foundation 2010 report that explored the financial efficacy of several healthcare Districts in the state, SVLHCD management has a goal to remain a small healthcare provider that provides limited healthcare services that are in high demand within its boundaries. District management’s approach to growth, the District’s “A” bond credit rating for, which reflects the District’s solid ability to raise revenues for capital projects, modest customer base and the slow population growth rate within district boundaries, it is determined that the SVLHCD presently has the capacity needed to accommodate current demand of healthcare services and has taken adequate steps to ensure that expected demand is accommodated well into the future. In the past year SVLHCD has upgraded its CT Scan, MRI and Interventional Radiology Technology. SVLHCD is in the process of updating the Medical Staff Development Plan, which identifies community need for physicians within various specialties. This plan is then utilized the recruit needed physician specialties to the area. It should be noted that the hospital’s service area is a Primary Care Health Profession Shortage Area and serves a medically underserved population. These areas experience higher demand for ER services. 3) Financial Ability of the Agency to Provide Services 1. The District has issued approximately $73.2 million in bonds, $18.7 million in 1998 and $54.5 million in 2007 in order to fund various expansion and other capital projects. These bonds were given an “A” rating by Fitch Ratings, affirmation that reflects a balance sheet marked by very strong liquidity, operating profile that exhibits very good and sustained profitability margins coupled with good debt service coverage and a dominant market chare (60% of service area). Fitch Rating’s credit risk analysis of the District also points out that Fiscal Year 2008-2009; the SVLHD reported $127.7 million in unrestricted cash and investment (17 times the cushion ratio), a 146% debt-to-cash position and $7 million in operating income. The fact that 40% and 35% of the Districts gross revenue comes from Medicare and Medi-Cal respectively was pointed out by Fitch Ratings as a credit concern. This most likely because having such a substantial proportion of its revenue dependant in these programs subjects the District to reimbursement risk from state and federal agencies, a risk that is magnified by California’s budget deficit and the overall economic downturn. 2. The budget submitted to the State Controllers Office by the District shows that it had $127, 5000,717 in revenues, $111,618,630 in expenditures and $73,270,473 in debt. 3. The District is one of eleven Challenging Payer Mix hospitals (CPM) used as a case study in a 2010 California Healthcare Foundation report for meeting or exceeding performance criteria on at least five of ten standard financial measures. Some of these measures include operating margins, operating cash flow, cash to debt and debt coverage ration. According to the report, the robust financial performance of the District is a result of a budgeting process focused on revenue cycle improvement, recouping payments for services rendered, reducing costs of temporary staffing, and maintaining an adequate volume of patients through careful service line development (a narrow scope of what services are most needed in the region rather than a wide array of services), and recruitment of physicians to the community. 4. The District is eligible to receive funding from several federal and state hospital subsidiary programs, including the Disproportionate Share Hospital and hospital outpatient services and adult day health services (AB 915) programs. The District received approximately $4.5 million, $1.6 million and $1.8 million respectively; approximately two-thirds from Federal DSH, Med-CSH and AB 915. 5. Like other area healthcare districts, the SVLHCD derives one percent of its operating budget from local taxes. The remainder of its budget is raised from patient charges and medical program reimbursements. The SVLHCD listed the following items as the primary sources of funds for the District: • Funds collected for services rendered to patients • Property tax revenues • Cafeteria revenue • Interest revenue • Grants Based on SVLHCD’s management’s goal of remaining a small and focused healthcare provider, the District “A” bond credit rating and its exemplary cost saving measure, it is determined that the District is in satisfactory financial health and is financially able to provide healthcare services to its residents now and into the foreseeable future. 4) Status of, and Opportunities for, Shared Facilities 1. As previously mentioned, the District only owns or leases facilities within its campus. This is a reflection of the focus placed by district leaders on excelling in being a community hospital, focus growth on service lines of greatest value to residents and to avert becoming a large regional medical center that offers many services at higher operational costs. 2. The District forms part of a second JPA that includes the Tulare Regional Medical Center and the Kaweah Delta Healthcare District, which was intended for the purpose of sharing services and/or joint purchasing. Since its formation the JPA has not been utilized. It is determined that the District is already exercising the most logical and feasible opportunities for shared facilities. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies Accountability for Community Services 1. SVLHCD’s productivity and overall performance is monitored by various Local, State and Federal agencies. Regulation includes: certification from the Medicare and Medi- Cal programs; permits for building, conditional use, expansion, renovation or replacement of major equipment form the Office of Statewide Health Planning and Development, the City of Tulare and from the San Joaquin Valley Air Pollution Control District; licensure from the State Department of Public Health Services; and must register its vehicles with the DMV. 2. The District received accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2003; and again in 2007. In October, 2010, Sierra View Local Health Care District received a 39-month accreditation from The Joint Commission (TJC). 3. The State Department of Public Health levies penalties on hospitals for administrative violations that jeopardize the health or safety of a patient (e.g. botched surgeries and disabilities associated with medication error) and for breach of a patient’s confidential medical information. Penalties can be as high as $100,000 per violation. The list of hospitals cited is published each year on the State Department of Public Health’s website. SVDH does not appear on the list for 2010. 4. The District maintains a website which informs the public of its services, activities and accomplishments. Unlike other healthcare districts in the region, the SVLHCD does not offer many publications that highlight district activities and accomplishments, most likely because of its intent to remain a small, limited service community hospital. 5. In 2005, the District implemented is “Journey to Excellence” program, which provided opportunities to staff members to travel to other hospitals to learn how to implement organizational and cultural changes in order to improve the quality of care and patent safety provided by the District. 6. As detailed in the background portion of this MSR, in accordance Government Code 56430 LAFCO is required to conduct a Municipal Service Review and make determinations. SVLHCD has responded to the request received in 2011. 7. A 2006-2007 Tulare County Grand Jury conducted an investigation into whether area hospitals are fulfilling the requirements set by the Emergency Medical Treatment and Labor Act (EMTALA), Section 1867 of the Social Security Act. The act proposes to protect those seeking emergency treatment from hospitals transferring, discharging, or refusing to treat patients coming to hospital emergency rooms. These practices are commonly referred to as “dumping”. The act applies to Medicare participating hospitals but protects all patients, not just Medicare beneficiaries. A detailed list of the EMTALA requirements is attached to this MSR. The investigation was prompted by the extensive media coverage regarding physician/surgeon shortages in Tulare County. The Grand Jury investigation focused on hospital emergency service and scheduling of surgical personal. Procedures followed: • Visited all areas hospitals • Interviewed relevant witnesses • Reviewed relevant documents The investigation found: • That the SVLHCD has established procedures to make sure that emergency personnel is available 24 hours per day, 7 days per week and 365 days per year. • The SVLHCD has on-call lists and schedules in place with nursing supervisors, trained in emergency procedures, who will call a physician/surgeon who then assembles a team to deal with the emergency. The process may take over an hour. • The SVLHCD treats approximately 50,000 emergency patients each year (the hospitals own records, cited above, give a lower estimate). • The SVLHCD has put in place an incentive fee schedule designed to attract local physician/surgeons for unscheduled medical duty. • The Kaweah Delta, Tulare District and Sierra View hospitals can call on each other to help in times of shortages. Based on the fact that the District operates within a heavily regulated industry, is currently undergoing the rigorous accreditation process through the Joint Commission on Accreditation of Healthcare Organization and the fact that the District has not been cited for any regulatory violations, it is determined that there adequate controls to ensure District accountability and transparency. Governmental Structure and Operational Efficiencies 1. The SVLHHCD Board of Directors is comprised of 5 members who are registered voters and reside within the District. District board members are elected at large and do not represent specified zones, districts or regions. 2. Regular Board meetings are held on the fourth Tuesday of each month at 8:00 AM. Meeting agendas are posted in the hospital and are also faxed and emailed to the Porterville Recorder and KTIP Radio Station. 3. The District employs 214 full-time, 1 part-time Registered Nurses (RNs) and 46 full- time and 2 part-time Licensed Vocational Nurses (LVNs). The number of healthcare practitioners and administrative staff employed by the District is unknown. 4. As mentioned above, the SVLHD was highlighted in a 2010 report prepared by the California Healthcare Foundation for its robust financial performance as compared to other CPM hospitals. The following are some the efficiency factors that led to the District’s success: • Full use of hospital units • Management of supply costs through supply chain and inventory management and standardization of supplies and equipment • Use of new product committees and similar structures to advise leadership on the necessity of purchasing new equipment and products and assessing the value and effectiveness alternatives • CFO approval of any expenditure above $10,000 • Flexible nurse staffing • Reduced use of temporary employees through staff recruitment and retention programs • Vigorous pursuit of payment for services rendered • Implementation of electronic medical records, picture archiving and communication systems and other information technology Based on the exemplary cost saving measures that the District has implemented and the fact that no regulatory violations were discovered, it is determined that the District is operated with a high degree of efficiency. Little is known about the actual governance of the District, but the District seems to hold regular meeting that are adequately noticed; thus, giving district residents the opportunity to provide comments and raise concerns regarding District services. Some of the challenges that management faces on an ongoing basis are: manpower shortages in areas like nursing, clinical and numerous technical and professional fields. Providing healthcare services to uninsured and underinsured patients while remaining financially viable and the rapidly changing demographics of the community are challenges that must be met head-on, not only for reasons of compassion and quality of life, but also because of the economic consequences that accompany inaction. 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Commission Policy Recommendations: The SVLHCD should exercise the JPA along with the KDHCD and the TRMC for the purpose of purchasing equipment and supplies thereby reducing costs to the JPA’s participants. Exeter District Ambulance Municipal Services Review Background This section provides an overview of the determinations of the Exeter District Ambulance (EDA) Municipal Service Review (MSR). As part of its review of municipal services, the Tulare County Local Agency Formation Commission (LAFCO) is required to prepare a written statement of its determinations with respect to each of the following: 1) Growth and population projections for the affected area; 2) Present and planned capacity of public facilities and adequacy of public services, including infrastructure needs or deficiencies; 3) Financial ability of agencies to provide services; 4) Status of, and opportunities for, shared facilities; 5) Accountability for community service needs, including governmental structure and operational efficiencies; 6) Any other matter related to effective or efficient service delivery, as required by commission policy. These requirements are established by Section 56430 of the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (CKH). The following determinations were largely derived from a questionnaire submitted by the EDA in 2007, Central California Emergency Medical Service Agency (CCEMS) policies and procedures manual, and the Sun-Gazette newspapaer. CKH Section 56430 has since been amended by AB 1744 (Ch. 244, Stats 2007). The MSR format used in the Group 1 and 2 MSR’s has been revised to reflect the new requirements of CKH 56430 as amended. Background Exeter District Ambulance (EDA) was established in October 1977 and provides emergency ambulance treatment and transportation service to 25,000 people in a 300 square mile area. The district encompasses all of Exeter and Lindcove and extends west to Raod 176, east to Road 236, north to Avenue 320 and south to avenue 256. The CCEMS and the County Board of Supervisors authorize ambulance provider agencies within Tulare County. Each provider agency is limited to provide service within a specific geographic area (with some exceptions) called Ambulance Service Areas. The EDA provides service within Tulare County Ambulance Service Area 5. 1 Written Determinations 1) Growth and Population Projections 1. As mentioned above the EDA boundaries include the City of Exeter the unincorporated area west to Road 176, east to Road 236, north to Avenue 320 and south to avenue 256. According to U.S. Census data, the population within district boundaries was 10,086 in 2000 and 14,621 in 2010. 2. The District has no intension to request an expansion of its current Ambulance Service Area. 3. A costumer is defined by the district as any person to which care is provided to by district EMT’s or paramedics and/or persons transported by EDA ambulances. 4. In addition the district serves costumers outside of the established Ambulance Service Area in cases where the EDA is the nearest provider agency. 5. Call frequency and volume is used to determine staffing. The District defines this as unpredictable. Population fluctuations within district boundaries are not necessarily a good indicator of fluctuations in service demand. Demographic and medical data such as population by age, income, gender, race and the susceptibility of these groups to certain diseases would provide a better picture of the demand for services. However, LAFCO Staff does not have the medical background to analyze such data and make such determinations. Based on the population data listed above, the lack of building permits for the unincorporated area within the district, and no annexation requests made by the City of Exeter, it can be determined with a high degree of certainty that the population within district boundaries will remain steady for the new 5-years. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The EDA defines a costumer as any person who is treated by district EMT’s or paramedics or any person who is transported to a hospital by a district ambulance. 2. The primary service areas for the EDA are Ambulance Areas 3, 5, and 13. This includes the cities of Exeter, Farmersville, Woodlake and the surrounding unincorporated areas. A map of Tulare County Ambulance 2 areas is attached to this MSR. The EDA also staffs an ambulance on Tuesday, Friday, and every 3rd Thursday of each month in the City of Lindsay. Pursuant to the contract between the EDA and Tulare County the District can respond to calls in any other area in the County. 3. The EDA operates out of 2 stations and owns/operates 4 ambulances. In addition the EDA owns 1 administration building. The District’s administration building is located at 302 East Palm in Exeter. 4. EMS equipment standards as well as EMS drug and solution standards are determined by the CCEMS Agency’s policies and procedures manual. This equipment is subject to inspection by CCEMS Agency personal for compliance with policies. 5. Response time standards and reporting requirements are also determined by CCEMS Agency policy. Response time is measured by the amount of time that elapses from the time a dispatcher receives a Code 3 call to the time an EDA ambulance reaches the scene. The response time standard for Tulare County providers is 13 minutes within a 5-mile radius of the ambulance base. The set standard of time must be met in 90 % of the cases that are reported to the CCEMS Agency. The EDA indicated that the average response time within the district is less than 7 minutes. 6. Responses that exceed 150% of the standard will be reviewed and documented as to cause and submitted to CCEMS by ambulance providers. The ambulance provider must submit monthly performance reports due within 15 days of the following calendar month. 7. In addition to response times exceeding set limits, the monthly performance report must also indicate the number of Code 3 calls received, percentage of calls meeting the standard, responses to calls outside service area and number of calls that were turned over to another zone. 8. The District indicated that there are no types of infrastructure and/or service that it considers inadequate. 9. The District indicated that it had no plans to upgrade infrastructure or expand service. According to the latest EDA monthly performance report, the District has met the required standard response time in the minimum required number of cases. Furthermore, the CCEMS indicates that there have been no reports of substandard EDA EMS equipment or drugs and solutions. This information suggest that the EDA has an adequate amount of ambulances, EMS equipment and trained personnel to meet current demand for emergency service within its designated Ambulance Service Area within the minimum required amount of time. However, LAFCO cannot make as determination as 3 to the quality of care provided by the district as data such as number of deaths due slow transportation, inadequate pre-hospital medical care, or patient surveys is unavailable. 3) Financial Ability of the Agency to Provide Services 1. District operations are funded by a special property tax approved by voters in 1977. 2. According to the 2008/09 FY budget (most recent budget available)\ the EDA began the fiscal year (July 1, 2008) with a cash balance of $541,581 and $309,331 in reserves. Revenue sources include: • secured property tax • bad debt collection • service charges • interest earned 3. For FY the 07/08 the EDA estimated that it would spend approximately $1 million on employee salary and benefits. Other expenses include services and supplies, long-term debt payments. 4. Based on budget information from FY 2008/09, FY 2007/2008 and EDA Board Presidents comments in the Sun-Gazette article published ion July 23, 2009 (before adoption of the 2009/10 budget) the EDA maintains a reserve of approximately $500,000 from year to year. Board President Kunkell stated in the same article that the general rule followed by the Board is to have a reserve amount sufficient to keep operations going for at least 4 months. 5. On July 22, 2009 the RDA Board voted unanimously to enter into a contract with Lifestar a Tulare based company to act as executive management overseeing personnel in both EDA operations management and paramedics. Lifestar would evaluate district personnel, policies and procedures and make recommendations to the board. Substantial cost savings were cited as the reason for this action. 6. The EDA has a rate schedule for the following services: • Advanced Life Support (ALS) • Basic Life support (BLS) • Mileage • Oxygen • Night Fee • EKG 4 7. The EDA has had a number of instances in the past where it was close to financial insolvency: o 1985- citizens raised $17,000 to prevent the EDA from dissolving o 1990- an unexpected charge for service previously provided for free by the CA Dept. of Fire that dwindled reserves o 2003- By this time service had been extended to Woodlake, Farmersville, Lindsay, and Three-Rivers but had to be withdrawn due to budget constraints that forced layoffs. o 2008- The County of Tulare was considering the establishment of a single ambulance provider Countywide. This would have forced the EDA to close because it would no longer have the funding to support operations. The District is primarily dependant on property taxes. This coupled with the fact that the state will be withholding a larger portion of local agency tax revenues to address the state’s budget shortfall makes it likely that the EDA will once again face financial hardship. The Board President is aware of this fact and was quoted as saying that FY 2009/2010 district reserves may have to be used to supplement a potential budget shortfall. It is determined that reserves will be sufficient to cover the projected budget shortfall projected for FY 2009/10. However, based on the large amount of employee benefits and salaries paid each year as compared to it district revenues, if the current economic conditions continue, a reduction in district staff or service may be necessary in order for the EDA to remain operational. 4) Status of, and Opportunities for, Shared Facilities 1. As mentioned above on July 22, 2009the EDA Board of Directors voted to enter into a contract with the Lifestar, a Tulare based company, for the sole purpose of managing operations. EDA EMT and paramedic staff will continue to work for the EDA. However, Lifestar does have EMT and paramedic staff that is available to provide support in case current EDA medical staff is unavailable. 2. The EDA has entered into an agreement with Tulare County that allows it to respond to calls from outside its service area. 3. If all EDA staff is unavailable the closest available ambulance provider can provide ambulance and pre-hospital care service to calls with the EDA’s Ambulance Service Area. 5 Lifestar has worked with ambulance providing agencies similar to EDA such as the ambulance service provider for the Pixley, Tipton, and Earlimart areas. This indicates that the contract that was entered into will result in cost savings for the district and the tax payers within the district. Although, there’s no written agreement or contract the fact that other agencies are able to provide service with the EDA when needed ensure that district residents have ambulance serve at all times. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies 1. The EDA is governed by a 5-member board of directors. Members are elected at large. The Board holds public meetings held the third Thursday of each month at 4:00 PM. Agendas are posted outside the district office. 2. The EDA staff and equipment must meet local and state licensing. Staff is required to take part in continued education training, EDA must submit monthly performance reports to the CCEMS, and all equipment drugs and solutions must also be inspected on a periodic basis. 3. Every patient transported requires a Patient Care Report which must be kept for 7 years. 4. Each EDA ambulance is staffed with a licensed paramedic (pursuant to its contract with the County). Each paramedic must abide by Title 22 of the California Code of Regulations which list the scope and practices of a paramedic. A copy of Title 22 is attached to this MSR. 5. The board’s decision to enter into a contract with Lifestar proved to be controversial. Many area residents complained that the not enough people were made aware of the potential action in a timely manner. In addition, the district president indicated that minutes for the March and June 2009 meeting were not taken. 6. The EDA does not operate a website. 7. In the Sun-Gazette article several board members indicated that applicants for board positions are rare. As of July 2009 they have one on file. Because of the nature of the service the EDA provides it must meet a higher number of standards and is subject to authorization and inspection more often than many special districts. That is why LAFCO determines that there are sufficient mechanisms in place to ensure that a high quality of service is maintained and monitored properly. However, LAFCO does recommend that minutes be taken at each meeting and that the District 6 should post on the internet materials including monthly performance reports, agendas, minutes, and rate schedule. The cost of creating and maintaining a webpage is a legitimate obstacle that must be considered. However, the District could work with other districts in a similar situation to combine their resources and raise the funds necessary to create and maintain a very simple webpage that will house basic information for each district or these districts can use their consolidated resources to pay another governmental agency (such as LAFCO or Tulare County) to house basic information for each district on their own website. 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Commission Policy Recommendations: There are no recommendations. 7 Healthcare Districts with Inactive Hospital Facilities In the late 1990s and early 2000s, increasing payroll costs, reduced Medicare reimbursements and the tremendous cost associated with retrofitting hospital facilities as required by seismic safety regulations established by the State Office of Statewide Health Planning and Development led many Healthcare Districts to cease hospital operations. Such is the case of the Lindsay Local Hospital District (LLHD) and the Alta Hospital District. In the case of the AHD, the mounting costs led the District to seek bankruptcy protection under Chapter 9 of the U.S. Bankruptcy Code. Both the LLHD and the AHD no longer directly provide healthcare services or maintain infrastructure, their roles have been reduced to the administration of property tax revenues, grants and other revenues for the purpose of providing for the health and safety of the communities they serve and for repayment of debt obligations. Alta Hospital District The AHD was formed in October of 1946. Its jurisdictional boundaries encompass an 84,660-acre area that includes the City of Dinuba and the Cutler-Orosi region. At the time the District ceased operations, it served an estimated population of 41,172 persons. The District’s Sphere of Influence (SOI) boundary is coterminous with its jurisdictional boundaries. The District provided inpatient and outpatient hospital procedures by contract with the Dinuba Surgery Center LLC (DSC). The DSC leased the District’s hospital facilities at a cost of $8,700 per month. As mentioned, the high costs of medical staff, healthcare technology and equipment, decreased Medicare reimbursement amounts and required retrofitting of hospital facilities put a financial strain on the District that forced it to initiate Chapter 9 Bankruptcy proceedings on August 21, 2001. In the ensuing years, several hearings were held regarding this bankruptcy case (Case No. 01-17857) in order to sort out claims and establish a repayment plan. One of the major issues to arise involved the sale of the District’s hospital facility. The City of Dinuba, contracted by the District to provide bankruptcy services, brokered sale of the hospital building to the DSC in the amount of $1,812,500. As part of the agreement between the City and the District, a portion of the sale proceeds was due to the City for services rendered and District property taxes would now be paid directly to the City. The sale was approved by the court and affirmed by the voters. Bank of the Sierra, one of the entities holding claim to District assets and/or revenues, initiated adversary proceedings against the City of Dinuba asserting various lien determinations and claims, including security (portion of loan contractually obligated to be paid from specific revenue source) from interests in the Districts property taxes. The fact that the DSC reneged on the purchase, although they continued to lease the facilities, further complicated the issue. The Court eventually decreed a settlement agreement under which Bank of the Sierra established $108,000 in secured claims and $698,404 in unsecured claims; the City of Dinuba was transferred ownership of the hospital building at no net cost; and the District received $640,140 from the hospital facility sale. Hospital ceased operations on October 10, 2001 and physically vacated the facility in 2004. Court records indicate that the District has 207 creditors with valid claims (last claim was filed in 2004). A repayment plan became effective in April of 2003 and was amended in 2004 to allow creditors to change classification status if they wish. Creditors are classified in one of the three following ways: those with claims under $500 (Class 1), those with claims of between $500 and $26,000 (Class 2) and those with claims in excess of $26,000. On the effective date of the plan, the District estimated 100 Class 1 creditors with claims totaling $20,000. Class 2 claims totaled $20,000-$350,000, depending upon the ultimate settlement amount (creditors can choose to reduce their claim in exchange for payment in full of at least 50% of their claim). Class 3 creditors can change to their classification status to Class 2 by agreeing to reduce the amount of their claim to $26,000 or less in exchange for 50% of their claim being repaid in full. Class 3 claims were estimated to be $3,467,657 total. The majority of this amount, $1,927, 024, is owed to the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid. Attorney Clifford E. Bressler was appointed as the administrator in this bankruptcy case by the Court on December 30, 2002 and his appointment was approved by the District on January 27, 2003. Mr. Bressler is responsible for the preparation of quarterly reports of all District receipts and expenditures and providing these reports to creditors and their counsel. Mr. Bressler is also responsible for submitting reports no less than every 6 months to the court which detail work done to date and debts repaid. The last progress report was submitted on January 21, 2011. The plan prescribes that Class 3 debts be repaid within 7-15 years in quarterly disbursements. The interest rate established by the court is 5%, unless debts are repaid in full, then a 3.5% interest rate is applied. A 6% interest rate will be applied to any debts remaining after 13 years. According to the most recent progress report submitted by the administrator, Quarterly disbursements total $50,000 to $60,000. All Class 1 claims have been paid in full. Class 2 and 3 disbursements total $1,971,004 to date. According to the State Controller’s 2010 Special Districts Report, the AHD reported $353,795 in total revenues for fiscal year 2007-2008 and $260,987 were reported in fiscal year 2009-2010. The District is allowed to hold a maximum of $50,000 in reserves. The current Board of Directors consists of four members (the fifth member recently passed away), all appointed by other board members. Two appointments were made in 2008 and one was made in 2010. Board meetings take place at the Dinuba Public Library and are held on an as needed basis. The last Board meeting was held on November 30, 2010. Quarterly reports required to be submitted to the creditors and their counsel are also submitted to Board members and interested parties via fax, email or regular mail. During a phone interview, the estates administrator indicated that the Board is not interested in dissolving the District once obligations are met. The district can provide a wide array of healthcare services afforded by its governing act, which extend beyond hospital services. Lindsay Local Hospital District The LLHD was formed in October of 1958 and its boundaries encompasses a 47,066-acre area (its SOI is also coterminous to its jurisdictional boundaries). Operation of the LLHD hospital was contracted out to the Sierra-View Local Hospital District in 1995. Sierra view went on to spend $15 million over a 5-year period to renovate the hospital building and upgrade hospital equipment. Like the AHD, the increased operational and regulatory costs forced the Sierra View LHD to cease hospital operations and transfer control back to the LLHD. Under an agreement executed in 1995, ownership of the hospital facility was transferred from the LLHD to the City of Lindsay. The LLHD, however, did not seek bankruptcy protection, but rather shifted its focus to providing for the health and safety of District residents through other healthcare programs. In the wake of the hospital closure, a Board meeting was held on January 30, 2001 to discuss how the estimated $300,000 in annual property tax revenues could be used. District and City officials in attendance suggested that remaining facilities could be used to establish health lifestyle centers through a joint City/District venture. The City of Lindsay was able to procure a $3 million Rural Development loan from the USDA for construction of a health center to serve the residents of rural Tulare County. The center was initially envisioned as a 21,000 square-foot, three-story building that included an indoor Olympic sized swimming pool, senior daycare facility, a fitness gym, physical therapy facility, demonstration kitchen and café and multi-purpose meeting rooms. The ambitious project has since been scaled down. The Lindsay Wellness Center, as it is now known, consists of a 14,000 square-foot facility intended to house workshops and seminars on healthcare topics and includes a nutritional demonstration kitchen and rehab facilities. The cost of the scaled down facility is estimated at $5 million, down from the original estimated cost of $7 million. The facility is owned and operated by the City of Lindsay; the LLHD only serves the role of helping to fund a portion of Center costs. The LLHD provides $233,000 each year toward City repayment of the $3 million USDA loan. This type of agreement is expressly allowed under GC Section 32121 (m), which states in part that a healthcare district has the power to establish, maintain, and operate or provide assistance in the operation of free clinics, diagnostic and testing centers, health education programs, wellness and prevention programs, rehabilitation, aftercare, and any other healthcare services provider, groups, and organizations that are necessary for the maintenance of good physical and mental health in the communities served by the district. Government Code Section 32126.5 (a) (2) further allows a healthcare district to provide assistance or make grants to nonprofit provider groups and clinics already functioning within the community. Several statutes in the Healthcare District Act allow for service to be provided outside of District boundaries. In a phone interview with a District Board member Bobbie Velasquez, Mrs. Velasquez indicated that the District adopted a role of a public agency that helps fund various programs and activities that provide for the good physical and mental health of district residents and residents of surrounding areas. Based on an examination of State Controller financial reports for the LLHD conducted by the Visalia-Times Delta, since hospital operations were ceased in 2000, the District has collected approximately $4 million in property tax revenues ($440,702 annually on average). Over a 10-year period, the District has made approximately $1.72 million in expenditures and approximately $1.91 million has been put away in reserves. The District has helped fund the following activities/programs: • Equipment for the Lindsay High School football team • A portion of the salary for a nurse staffed by Lindsay’s Healthy Start Program • Matching funds for a Agricultural Worker Health and Housing Program grant awarded by the Rural Communities Assistance Corporation • City Wellness Center Solar Panels The expenses accrued by the District include $60,000 for Board member salaries, an average of $1,200 per member per year. Government Code Section 32103 details Board member compensation. The statutes state that the board of directors shall serve without compensation except that the board of directors, by resolution adopted by majority vote of members of the board, may authorize the payment not to exceed $100 per meeting not to exceed 5 meetings per month as compensation to each member. Based on the statute and the financial data available, it seems District Board members are collecting the highest compensation amount allowed under the law (provided that additional special meetings were not held) and that the board meets each month and has a full board present at each meeting. LAFCO Staff needs to review District meeting minutes to verify that this in fact the case. The LLHD Board of Directors meets on the third Monday of each month at 7:00 PM at the Lindsay City Hall. 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There are 12 mosquito-borne diseases that are known to occur in California but only West Nile Virus (WNV), western equine encephalomyelitis virus (WEE) and St. Louis encephalitis virus (SLE) are significant causes of human diseases. In 2007 there 380 human cases of WNV reported state wide with 21 resulting in death. These viruses are maintained in wild bird and mosquito cycles that do not depend upon infections of humans or domestic animals to persist. The California Mosquito-Borne Virus Surveillance & Response Plan drafted by the California Dept. of Public Health Mosquito & Vector Control Association of California recommends that surveillance and control activities focus on this maintenance cycle, which involves primarily culex mosquitoes, such as the western encephalitis mosquito, culex tarsalis and birds such as house finches and house sparrow. Immature stages of the culex mosquito (known as larvae and pupae) can be found in a wide variety of aquatic sources, ranging from clean to polluted waters. The majority of aquatic sources are associated with irrigation of agricultural lands or urban wastewater. There are no known specific treatments or cures for diseases caused by these viruses and vaccines are not available for public use. WEE infections tend to be more serious in young children while infections caused by WNV and SLE viruses most seriously affect the elderly. An effective way of providing abatement service is through well-planned integrated pest management commonly referred to as an IPM program. The primary components of such a program include education, surveillance and actual control of adult and immature mosquito populations. Integrated Pest Management (IPM) Components Education: Residents and Farmers need to be informed of the various things they can do in order to prevent the development or eliminate prime breeding grounds for carriers of vector-borne diseases. Examples include properly disposing of discarded tires, cans, or buckets; emptying plastic or unused swimming pools; and unclogging blocked rain gutters. Farmers and ranchers can be instructed to use irrigation methods that do not allow water to stand around for long periods of time. Other information that should be provided to the public includes curtailing outdoor activities during peak mosquito biting times, use of insect repellent and the use of long sleeved clothing that will help reduce exposure to mosquitoes. 1 Surveillance This component of IPM includes the monitoring and analysis of climate data, estimating immature and adult mosquito populations (commonly referred to as abundances) and assessing virus activity by testing samples of mosquitoes and other vector-borne disease carriers as well as humans. Sample Collection Methods: Sample collection and testing is a major focus of surveillance. Both immature and adult samples or collected in order to provide a comprehensive level of surveillance. Samples of larvae and pupae are collected from known and new aquatic sources. Careful records are kept of the number of adult occurrences, if the habitat from which the sample was obtained was treated (physical, biological or chemical) and at what development stage the population was in when treatment was applied and source size. This data can be used to forecast the size of the adult population and to guide control operations. The adult and immature mosquito samples are collected using the following tools: New Jersey light traps, carbon dioxide-baited traps, gravid (egg-laying) traps and resting adult mosquito collection. The pros and cons of each sampling method, design guidelines, operation and process are summarized in the attached California Mosquito-Borne Virus Surveillance & Response Plan Appendix A. Samples are sent to the Arbovirus Research Unit of the Center for Vector-borne Diseases (CVEC) at UC Davis for testing. Mosquito Control: The problems detected by surveillance are mitigated through larvae and adult control. The chemical compounds currently approved for larvae and adult control are listed in appendix H of the attached California Mosquito-Borne Virus Surveillance & Response Plan. Environmental management, biological control, chemical control or a combination of some or all of these methods can control larvae and adult mosquito populations. Environmental management consists of habitat removal and water management through evaporation, percolation, recirculation, or drainage of stagnant water sources. An even distribution of irrigation water is also encouraged along with removal of vegetation conducive to mosquito breeding. Biological control involves the use of natural mosquito predators such as mosquito-fish (Gambusia Affinis) and other microbial control agents. Chemical control is used to suppress populations of infected mosquitoes or interrupt an epidemic. These chemicals are applied in ultra low volume (ULV) dosages and 2 formulations. The following are common agents used: organophosphates such as malathion and naled, pyrethroids such as resmethrin, sumithrin, and permethrin, and pyrethrins such as Pyrenone crop spray. Determining Response Levels The California Mosquito-Borne Virus Surveillance & Response Plan was developed to provide a semi-quantitative measure of virus transmission risk that could be used by local agencies to plan and modulate control activities. The following are the 8 factors that the State recommends should be measured and analyzed to determine the potential for virus transmission and thereby gauge the appropriate response level: 1. Environmental Conditions 2. Adult Mosquito Vector Abundance 3. Virus Infection rate in mosquito vectors 4. Sentinel chicken seroconversions 5. Fatal infections in birds 6. Infections in equids and ratites (e.g. emus and ostriches) 7. Infections in humans 8. Proximity of detected virus activity to urban or suburban regions Each factor is scored on a scale from 1 to 5 with 5 being the highest level of severity. The mean score corresponds to a response level as follows: (1.0 to 2.5) – normal season (2.6 to 4.0) – emergency planning (4.1 to 5.0) – epidemic Appendix B of the California Mosquito-Borne Virus Surveillance & Response Plan provides a worksheet that assists local agencies in determining the appropriate rating for each risk factor for viruses of concern. Key Agency Responsibilities for Local Mosquito and Vector Control Agencies The following are the key responsibilities of local mosquito and vector control districts as outlined by the California State Public Health Agency: • Gather, collate, and interpret regional climate and weather data. • Monitor abundance of immature and adult mosquitoes. • Collect and submit mosquito pools to CVEC for virus detection 3 • Maintain sentinel chicken flocks, obtain blood samples and send samples to VRDL. • Pick-up and ship dead birds for necropsy and WNV testing, or test oral swabs from American crows locally via rapid antigen screening assays. • Update CDPH weekly of all birds that are independently reported and/or tested by VecTest, RAMP or immunohitochemistry via their email arbovisrus@dhs.ca.gov • Conduct routine control of immature mosquitoes • Conduct control of adult mosquitoes when needed • Educate the public on mosquito avoidance and reduction of mosquito breeding sites • Coordinate with local Office of Emergency Service personnel • Communicate regularly with neighboring agencies 4 Delta Vector Control District MSR This section provides an overview of the determinations of the Delta Vector Control District Municipal Service Review (MSR). As part of its review of municipal services, the Tulare County Local Agency Formation Commission (LAFCO) is required to prepare a written statement of its determinations with respect to each of the following: 1) Growth and population projections for the affected area; 2) Present and planned capacity of public facilities and adequacy of public services, including infrastructure needs or deficiencies; 3) Financial ability of agencies to provide services; 4) Status of, and opportunities for, shared facilities; 5) Accountability for community service needs, including governmental structure and operational efficiencies; 6) Any other matter related to effective or efficient service delivery, as required by commission policy. These requirements are established by Section 56430 of the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (CKH). The following determinations were largely derived from a questionnaire submitted by the DVCD on October 4, 2007. CKH Section 56430 has since been amended by AB 1744 (Ch. 244, Stats 2007). The MSR format used in the Group 1 and 2 MSR’s has been revised to reflect the new requirements of CKH 56430 as amended. Other sources that were used include published articles from the Visalia-Times Delta, Porterville Recorder, State Department of Public Health website, the Tulare County General Plan Update and the State’s Department of Finance. District Background The Delta Vector Control District (DVCD) has provided comprehensive mosquito-borne disease control in northern Tulare Co. since 1922. The district encompasses an area of 712 square miles. The provision of service by the DVCD is a collective effort conducted along with the Mosquito & Vector Control Association of California (MVCAC), California Department of Health Services (DHS) and the University of California at Davis (UCD) and Berkeley (UCB). As previously mentioned the California Arbovirus Program recognizes that the western equine encephalomyelitis virus (WEE; St. Louis encephalitis virus (SLE) and West Nile virus (WNV) are significant causes of human disease. The viruses are maintained in nature in the wild bird and mosquito cycles that do not depend upon infection of humans or domestic animals to persist. The district’s surveillance and control activities focus on this maintenance cycle, which involves primarily the western encephalitis mosquito, culex tarsalis. 5 The components of the DVCD’s IPM program are addressed in the CEQA Preliminary Assessment of Integrated Pest Management Practices Used to Reduce the Risk of Mosquito-Associated Disease and Annoyance, adopted January 14, 2004. The primary aspects of the program include education, surveillance and mosquito control. Surveillance efforts include monitoring of climate data, estimating immature and adult mosquito populations and assessing the virus activity by testing mosquitoes and sentinel chickens. The district also collects and tests dead birds. Written Determinations 1) Growth and Population Projection 1. Based on 2010 census block data, the current population within the District’s boundaries is 240,150 persons and includes 57,488 households. 2. The district covers an area of 453,173 acres (708.1 squared miles). The district’s Sphere of Influence (SOI) and its service boundaries are contiguous 3. Included within the district’s boundaries are the cities of Dinuba, Visalia, Woodlake, Exeter and Farmersville. 4. The District defines a costumer as any person residing within its boundaries or residing in an area it has served (the District sometimes provides service outside of its boundaries). Using this definition the district estimates to have approximately 250,000 costumers (2008). 5. The DVCD does not have a comprehensive planning document that addresses projected population growth and how the corresponding level of demand will be addressed. The district uses the California Mosquito-Borne Virus Response Plan as a guide to determine the threat level of disease transmission (level of need for its services) and provide an appropriate response. The California Department of Public Health- Division of Communicable Diseases Control Vector-borne Disease Section outlines service practices. 6. The District indicates that it is in the process of developing a strategic plan that examines population growth trends and outlines a strategy to deal projected growth. 6 7. The District tracks weather conditions such as snow pack, spring rainfall, spring temperature and winter freeze conditions to project the potential level of demand for abatement services. 8. In order to gauge the level of future urban development that will take place within its boundaries and how much agricultural/open space land will remain, the District gathers data from and communicates with the following County agencies: a. Tulare County Ag Commission b. Tulare County Health and Human Services c. Tulare County Resource Management Agency d. Unincorporated Communities The Tulare County General Plan Update calls for development within the District’s unincorporated area. The approximate 2.7% population growth rate experienced within district boundaries over the last Census period indicates that the District’s population will continue to grow at a steady rate. Despite the projected increase in population and development, the area with district bounds will remain substantially rural. Mosquitoes thrive in rural areas comprised of agricultural/open space lands because irrigation of these lands produces sedentary water sources creating a prime breeding area for mosquitoes. Sedentary water sources coupled with increased urban wastewater from the increased population will increase prime mosquito breeding habitats. The increases in population will also increase the number of potential bite victims; thus, higher potential rate of infection. It is determined with a high degree of certainty that demand for mosquito control service will increase in the future. From the information available the District does not have a comprehensive planning document that projects the impact of these changes and outlines methods to address them. The District; however, is in the process of preparing such a plan, one that will focus on further developing the District’s surveillance program. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The district owns and operates a single building located at the following address: 1737 W. Houston Avenue Visalia, CA. 93279-0310 2. 13 New Jersey Light Traps are maintained throughout the district and are used as a tool to monitor adult mosquito populations. 7 New Jersey Light Trap Locations Visalia (3) Woodlake (2) Along Kings River (2) Cutler, Dinuba, Exeter, Farmersville, Goshen, Ivanhoe (1 each) 3. Samples collected are sent for testing at the State Center for Vector-borne Disease Research UC Davis at a cost of $20/sample (12-15 mosquitoes equal one sample). From the information available, sample testing is not conducted at the DVCD’s facility. 4. The most recent data indicates that DVCD lab staff has processed over 50,000 immature mosquito species through use of CO2 and Gravid traps set throughout the County in 2008. The following are sample results from various types of traps: • New Jersey Light Traps- 3,186 male and 5113 female adult mosquitoes. • CO2 Traps- 51,896 adult mosquitoes. 53 tested positive for WN. • Gravid Traps- 3032 adult mosquitoes. 9 tested positive for WN. 5. In 2008, 489 dead birds were reported to the District. 138 were submitted for testing. Of those 138 dead birds submitted 45 tested positive for the West Nile Virus (WNV). 6. The district owns the following equipment: 33 Vehicles 1 Bobcat Skid Steer Loader 1 4 X 4 Quad 2 Argo All Terrain Vehicles (Conquest 8 X 8) 2 Utility/Car Trailers 2 Beecomist ULV Fogger 2 London Fog ULV Fogger 1 Leco ULV Fogger 1 110-gallon A-1 Mist Blower 1 500-gallon skid mounted spray system 1 5 hp Honda Outboard motor 2 Echo Powered Backpack Mister Duster 4 Maruyama Powered backpack mister/ duster 2 Maruyama Power backpack sprayer 1 Solo Power backpack sprayer 8 All equipment is stored at the District’s Visalia location 7. The DVCD’s single Visalia location is not only used to store district equipment, chemical and biological agents but also for the design/construction of new equipment and district board meetings. 8. In 2007 the District began using electronic Geographical Information System to track and map 49,752 district activities including personnel contracts, service request, locations where mosquito eating fish were planted, source inspections, physical control projects, herbicide applications and chemical control efforts. This eliminated two (2) full-time positions that were filled 4 months out of each year. 9. The District has begun a 3-year project to build a new laboratory. Construction of the new lab will be completed in three phases. Phase 1 will be the concept phase (1st year). Phase 2 will be the design phase (2nd year). Phase 3 will be the building phase (3rd year). The project is expected to be completed during the 2010/2011 fiscal year and the goal is to expand the District’s surveillance program capacity. 10. Infrastructure and facilities used for mosquito abatement include buildings and labs and various form of equipment placed throughout the district. The District seems to have adequate capacity to provide surveillance service to residents within its boundaries as well as areas outside of the district. The District’s single location seems adequate for storage of the various traps and equipment used for its surveillance efforts. The District recently provided service to the southeastern portion of the County through a contractual agreement with Tulare County. The planned lab construction will allow the district to keep up with an expected increase in demand for service. 3) Financial Ability of the Agency to Provide Services 1. Michael L. Oxenreider CPA conducted the District’s financial audit for the Fiscal Year ending June 30, 2007. 2. The District’s budget is approved in July of each year by the Districts board of directors. 3. Primary Sources of Revenue: • Ad-Valorem Property Taxes (87%) • Interest from Investment Capital (4%) 9 • Other Charges (9%) 4. The average Ad-Valorem rate tax (pre ERAF) for the district is .024 . 5. Total revenues for FY 2007/08 were $2,171,973, up from $1,891,957 in FY 2006/07. 6. FY 2007 expenditures dropped from $ 1,855,901 in 2006 to $1,686,931. The $ 175,648 decrease is a result of restructuring the districts operational program. 7. The primary expenditures listed below are in order from most costly to least costly: • Salaries and employee benefits • Service and Supplies • Contingencies • Capital Outlay 8. The District has a current reserve fund balance of $2,383,863. Assets • Land ($8,776) • Building and Improvements ($1,009,515) • Vehicles ($683,394) • Equipment (368, 156) • Accumulated Depreciation (-$1,264,298) • Net Capital Assets ($805, 543) The District has a consistent source of revenues and possesses a robust reserve fund as well as several assets. There is no evidence that service has been hindered due to financial constraints. The District is in good financial health and has the ability to provide service into the future. 10 4) Status of, and Opportunities for, Shared Facilities 1. The DVCD operates and owns a single facility and does not share or jointly operate any other facility. 2. The district receives testing support, chemical application guidelines and biological implementation methods from the following agencies: • U.S. Fish and Wild Life Service • State Department of Fish and Game • Department of Pesticides Regulation • Ag Commission • State and County Department of Public Health • State and County Department of Environmental Health • University of CA. Davis and Berkeley 3. A portion of their southern boundary, which encompasses the south Visalia area, was identified by the DVCD as a region with overlapping/duplicate service. The area is within the boundaries of the Tulare MAD but both districts provide surveillance and response service to the area. All chemical and biological service requests received by the DVCD are referred to the Tulare MAD. 4. The District has provided abatement service to the southeastern portion of the County pursuant to a contract for services between the DVCD and the Tulare County Health and Human Services Agency. 5. The DVCD is part of the Vector Control Joint Powers Authority. The JPA was formed in order to exercise joint purchasing power for the following items: • Liability coverage • Excess liability coverage • Employment practices liability coverage • Workers compensation coverage • Excess workers comp coverage • Auto physical damage coverage • Public entity property insurance program 6. The DVCD also participates in the South San Joaquin Valley Mosquito and Vector Control Joint Chemical Purchase Agreement. This joint purchasing effort reduces the districts costs ensuring that the district has access to all chemicals necessary to provide efficient chemical control service. 11 Through its participation in joint powers authorities and joint purchasing agreements, the District is already pursuing the most logical and feasible cooperative opportunity. No other opportunity for shred facilities can be identified. However, the existence of overlapping service in the Visalia Area should be examined further to ensure that area residents are provided quality service in a timely and efficient manner. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies 1. A 7-member board of directors governs the DVCD. Members are appointed by the Tulare County Board of Supervisors and the city councils of the cities located with district boundaries. Members are appointed to 2 year staggered terms. 2. The Board meets on the second Wednesday of each month. Regular meeting time is 7:00 pm and regular meetings are held at the District’s facility in Visalia. 3. All board meetings comply with the rules and regulations of the Brown Act. 4. The District is divided into 6 zones. Each zone is a 160 squared mile area. Certified vector control technicians are assigned to each area and conduct the full range of abatement services as needed. 5. Part of the district’s integrated pest management (IPM) includes public outreach and resident education consisting of: • School presentations • Service Club presentations • Homeowner groups • Government Agencies 6. A Safety Committee has been formed and meets on a monthly basis. The Committee is comprised of employees from the various district departments. The purpose of the committee is to monitor employee practices and implement safety measures such as the District’s safety incentive program. 12 7. Integrating the Districts service data into a comprehensive electronic format, which eliminated two full-time positions that were manned during a 4- month period each year, saved the District a thousands of dollars. In addition the new format makes service information more accessible to the public and public agencies. 8. The District also responds to phone inquiries and complaints. 9. The District operates a web page www.dltavcd.com . The page contains Safety Committee meeting notices, Board meeting notices and information on what residents can do to reduce the threat of vector-borne diseases. 10. The District employs 2 professionals with a science degree. The following is a break down of district personnel: Executive Management Professionals Operational Full-Time 1 - 2 10 Part-Time - - - 2 Seasonal - - - 10 Contract - - - - 11. A mailing list of people who receive a board meeting agenda packet is maintained electronically. 12. The District maintains a spray notification email list. 13. The District has received various awards for provision of its abatement service. 14. In 2007, a reorganization of personnel resulted in the reduction of 2 full- time positions. This action corrected a negative spending trend, which increased both revenues and efficiency of service provision. 15. The California Department of Public Health- Mosquito-Borne Virus Surveillance and Response Plan governs the District’s activities. District board meetings comply with all public hearing legislation. The District makes all board meeting and district administrative activities readily available via its web page. The web page is up to date and easy to use. In addition, the District uses geographical information systems software (GIS) to keep track of district fieldwork such as trap locations and treatment of mosquito breeding sources and continually updates the information. It is determined that there adequate controls in place to provide for District accountability, transparency and efficiency. 13 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Commission Policy Recommendation: As mentioned above, a portion of the District’s southern boundary, which encompasses the south Visalia area, was identified by the DVCD as a region with overlapping/duplicate service. The area is within the boundaries of the Tulare MAD but both districts provide surveillance and response service to the area. It is recommended that the issue be examined in more detail to determine if district lines must be adjusted in order to end the duplication of mosquito abatement service in the area. 14 Tulare Mosquito Abatement District MSR This section provides an overview of the determinations of the Tulare Mosquito Abatement District (Tulare MAD) Municipal Service Review (MSR). As part of its review of municipal services, the Tulare County Local Agency Formation Commission (LAFCO) is required to prepare a written statement of its determinations with respect to each of the following: 1) Growth and population projections for the affected area; 2) Present and planned capacity of public facilities and adequacy of public services, including infrastructure needs or deficiencies; 3) Financial ability of agencies to provide services; 4) Status of, and opportunities for, shared facilities; 5) Accountability for community service needs, including governmental structure and operational efficiencies; 6) Any other matter related to effective or efficient service delivery, as required by commission policy. These requirements are established by Section 56430 of the Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (CKH). The following determinations were largely derived from a questionnaire submitted by the Tulare MAD on September 10, 2008. CKH Section 56430 has been amended by AB 1744 (Ch. 244, Stats 2007). The MSR format used in the Group 1 and 2 MSR’s has been revised to reflect the new requirements of CKH 56430 as amended. Other sources that were used include published articles from the Visalia-Times Delta, State Department of Public Health website and the State Department of Finance website. District Background The Tulare Mosquito Abatement District was formed in January of 1943. It covers 359,680 acres (562 square miles) located mostly in the southwestern portion of Tulare County. The District’s boundaries are contiguous and this area is the District’s Sphere of Influence (SOI). The District has a six member Board of Trustees. Trustees are appointed by the County Board of Supervisors and the cities of Tulare and Visalia. The Board of Trustees meet on the 2nd Tuesday of each month at 1:00 pm at the District’s operating site located on the City of Tulare’s Mefford Field Airport, 6575 Dale Fry Road. The District also coordinates its service provision efforts with the Mosquito & Vector Control Association of California (MVCAC), California Department of Health Services (DHS) and the University of California at Davis (UCD). The District uses the DHS’s California Mosquito-Borne Virus Surveillance and Response Plan and Operational Plan for Emergency Response to Mosquito-Borne Disease Outbreaks as guidelines in the District’s operations. These guidelines for mosquito control are used by all districts in California to effectively accomplish surveillance, biological control, and chemical control in their service areas. Written Determinations 1) Growth and Population Projection 1. The approximate population within the District boundaries is 195,000. This estimate was provided by the District using their GIS Census Tract information. 2. There are 273 dairies that operate within the District’s boundaries. New dairies continue to be added and existing operations continue to expand. Dairy waste water retention ponds located on dairies are a prime breeding source for mosquitoes in the District’s service area. Controlling this source of mosquito breeding requires a large expenditure of funds from the District’s operating budget 3. The district received 90 service calls from residents in their service area in 2010. 4. Incorporated cities in the district include the City of Tulare and a portion of the south side of the City of Visalia. 5. The District’s Annual Operational Report prepared by the district manager and adopted by the District’s Board of Trustees serves as a source of planning for the new year. The Annual Operational Report examines operational costs and service area functions. District management uses this information to review overall operational needs and review the District’s ability to meet the California Department Of Health Service’s criteria for effective mosquito control. 6. The District also uses the correlation between increases in population and an increase in service requests to aid in forecasting service demand levels. 7. The District’s management maintains communication with officials in the cities of Tulare and Visalia as well as unincorporated towns in the district to stay informed of their growth and development. District management also works closely with the Tulare County Resource Management Agency, Code Enforcement Department. Dairy operators are required by their Tulare County Operating Permits to maintain waste water retention ponds with adequate roads for inspection, spray treatment and weed control to allow effective treatment of mosquito breeding in this source. The approximate 2.7% population growth rate experienced within district boundaries over the last Census period indicates that the District’s population will continue to grow at a steady rate. Despite the projected increase in population and development, the area within district bounds will remain substantially rural. Mosquitoes thrive in rural areas comprised of agricultural/open space lands because irrigation of these lands produces sedentary water sources creating a prime breeding area for mosquitoes The expected increase in population both within and near the district will most likely increase the demand for its services due to the increase in potential infection victims and an increase in urban wastewater sources, which are a prime mosquito breeding habitat. Approval of new dairies within the District will also increase the number of water sources increasing the probable demand for mosquito abatement control services. 2) Present and Planned Capacity of Public Facilities and Adequacy of Public Services, Including Infrastructure Needs or Deficiencies 1. The District’s operational facilities are located on Mefford Field airport in the City of Tulare at, 6575 Dale Fry Road. The District leases a site on the airport from the City of Tulare. The lease is a 15 year lease with a right for 15 year renewal upon the expiration date. The lease rate is $774 per month with a built in CPI adjustment. This site serves as the District’s only fixed location for support facilities and equipment storage. 2. Infrastructure owned by the District includes the following: • The operational facility at Mefford Field includes, office space, Board of Trustee meeting room, laboratory, shop, hanger, and vehicle storage • Yard area with building and tanks for insecticide storage • 13 vehicles varying in size from 1 to ½ ton units available for inspection and treatment of mosquito breeding sources. • One aircraft configured for both normal and Ultra Low Volume spray applications. • Miscellaneous hand-held equipment for spray applications. 3. There are 9 New Jersey Light Traps set throughout the district and they are used as a tool to monitor adult mosquito populations. They are located in Tipton, Pixley, Alpaugh, Woodville, West Tulare, South Tulare, Creighton Ranch, Allensworth and South Visalia. 4. The District also collects adult mosquitoes for testing using CO2 traps. Placing CO2 traps in various locations in the district provides early detection of mosquito borne viruses in the service area. During the 2010 season 110 mosquito pools were submitted to the Center for Vector-Borne Disease (CVEC) for testing. Confirmation was received that 14 of these pools tested positive for the West Nile Virus. This information allows district personnel to increase surveillance and spray treatment in critical areas. 5. The District collects dead birds to send in for testing through the CDHS Dead Bird surveillance program. During the 2010 season 18 birds were collected and sent to the UC Davis Center for Vector-Borne Diseases (CEVEC). Twelve birds tested positive for the West Nile Virus. 6. In 2010 the Tulare MAD treated a total of 17,852 acres of land for mosquito control. Ground applications were made on 11,751 acres using spray vehicles and other hand held equipment. The district aircraft was used to treat 6,101 acres. 7. The District is divided into 4 zones and each zone is assigned a full-time technician. In addition the District hires 3 seasonal operators to work throughout the District during the season. 8. The District has highlighted an unprecedented outbreak of a deadly mosquito-borne virus as its main threat. Funding is available for this unexpected occurrence through Contingency Funding in the District’s budget. In fiscal year 2009/2010 the budget allocation for Contingency Funding was $234,045. 9. The District shares the domestic water supply for its facilities with four other tenants on Mefford Field. The four tenants share joint maintenance and operation of the domestic water supply infrastructure. 10. During 2010 the District worked with Tulare County LAFCO’s East County Abatement Steering Committee to extend service on the Eastern border of Tulare County. A survey was completed by the District working with a consultant, the SCI Consulting Group, to determine if the cities of Lindsay, Porterville and County wide areas in Eastern Tulare County would be willing to vote for a service charge via Proposition 218 for mosquito control. A sample survey was sent to a cross section of property owners. Results from this survey did not show support for passage of a full ballot measure under Proposition 218 to fund mosquito control in this area. Any expenditure beyond the $20,631 made by the District to extend service to this area is not feasible at this time. However the Tulare MAD remains concerned regarding lack of service in this area of Tulare County. The District has been contacted by residents from this area for service in past seasons and this will obviously continue. The infrastructure and facilities of mosquito abatement districts is not limited to buildings, equipment used to provide service should also be examined in this section as the majority of the Districts operation takes place away from district facilities. The District has traps set throughout a large and varied portion of the district, which indicates it has the capacity to adequately provide the surveillance component of its abatement service. The District’s Mefford field facility, which includes office space, shop, hanger, yard area and tanks for insecticide storage is secure with a long term lease with the City of Tulare. This space meets present operational needs and provides room for any unforeseen expansion requirements. The District is the only mosquito abatement district in the County with an aircraft at its disposal. The aircraft is available at cost to other districts if needed in the County and is invaluable to the TMAD District when large areas require spray treatment for mosquito control. 3) Financial Ability of the Agency to Provide Services 1. The District’s 2009/2010 fiscal year audit was conducted by the Certified Public Accounting firm Adair & Evans. 2. The District’s primary source of revenue is derived from ad-valorem property taxes. The District’s share of ad-valorem property taxes for the 2009/2010 fiscal year totaled $1,083,613. Miscellaneous revenue sources that include City of Tulare and City of Visalia redevelopment tax increments totaled $50,662. Total district revenues for 2009/2010 were $1,134,275. Primary Sources of Revenue: • Ad-Valorem Property Taxes (96%) • Miscellaneous Revenue Sources (4%) 3. The beginning Tulare MAD balance for 2009/2010 was $2,978,933. The ending balance for 2009/2010 was $3,354,061. 4. The District divides its direct expenditures into two categories, salaries and employee benefits and services and supplies. For the 2009/2010 fiscal year, employee salaries and employee benefits totaled $391,563 and includes items such as wages, social security, insurance and extra help. Services and supplies totaled $365,067. This category includes such items as mosquito larvicides, traps and infrastructure maintenance. 5. The District categorizes new equipment as fixed assets. In 2010 this included one ½ ton pickup truck for $19,932. 6. Total expenditures in 2009/2010 was $895,246 for salaries and employee benefits, Services and Supplies. 7. Following direct expenditures of $895,246 for 2009/2010 and receipt of funds received there was an ending balance of $3,354,601 available for 2010/2011. This funding is available for direct expenditures, Salaries and Benefits, Services and Supplies, Contingency Funding, Designated Reserves and General Reserves for the 2010/2011 Budget. The funds available are adequate for all anticipated operational needs of the District and provides funding for unforeseen emergencies. 8. Based on the amount of acres that were treated in 2010 for mosquito control, the cost per acre for ground applications was $89.86. The cost per acre for aerial treatment was $2.90. The cost per acre when using the aircraft is much lower since it is only used to treat large areas. The District has a consistent source of funding and is well positioned with reserve funds. This indicates the district will remain financially healthy in the long term and have funds for normal operations as well as emergency outbreaks for additional service as required. Breaking down all expenses in the District’s Operational Report allows accurate tracking of expenses and allows management to effectively plan for the next season’s service expenses. A large carryover of funds available allows district management to establish designated reserves for anticipated expenses, plan for equipment purchase, hire personnel, increase surveillance of district areas and meet any additional needs that may occur. 4) Status of, and Opportunities for, Shared Facilities 1. The Tulare MAD as previously stated leases their operating site from The City of Tulare on a long term lease. All of the buildings and equipment are owned by the district. Operating from a site on The City of Tulare’s Mefford Field Airport allows the convenience of operating the District’s aircraft from their main operating site on the airport. As previously mentioned the District shares a domestic water supply with four other Mefford Field tenets. This is also a convenient arrangement since large amounts of water are needed for loading equipment to accomplish spray applications on sources in the District’s service area. 2. Mosquito pools collected for testing to detect the presence of mosquito-borne viruses in the district are sent to the State Center for Vector-borne Disease Research UC Davis in coordination with the Department of Public Health Services. The convenience and availability of this state of the art testing facility is essential as well as cost effective versus the District’s creation of its own virus testing facility. 3. A portion of the Tulare MAD’s northern service area extends into the City of Visalia’s southern boundary. The District’s service area now in the City of Visalia’s has occurred over time as the city has extended its boundary into the District’s service area. When the Tulare MAD was formed this area was not a part of the City of Visalia. However there is no duplication of service in regard to Delta Vector Control’s service of the major portion of the City of Visalia. Tulare MAD will service this area of the District included in the City of Visalia’s boundary and additional areas of the city as they become part of their service area. 4. In 1999 the Tulare MAD provided surveillance and treatment of sources in the southeastern portion of the City of Porterville. This was done through an agreement with the Tulare County Agricultural Commissioner. The district as previously mentioned in this report in 2009/2010 explored extending service to this area working with the Tulare County LACO East County Abatement District Steering Committee. However this survey indicated property owners would not vote to support a fee for service in their area. 5. The District provides service of its aircraft at cost to other mosquito abatement districts that serve Tulare County. Using an aircraft allows a district to cover larger areas more efficiently than ground spraying and eliminates the need for additional manpower and resources. 6. The District is part of a Continuation Education Program coordinated through the California Mosquito and Vector Control Association (CMVCA) and the State Department of Public Health so that district personnel maintain California Certified Technician status. 7. The Tulare MAD forms part of the Special District Risk Management Authority (SDRMA) which works together to purchase the following types of insurance at a reduced price: • General Liability • Public Officials and Employee Errors • Personal Liability Coverage for Board Members • Employment Practices Liability • Employee Benefits Liability • Employee Dishonesty Coverage • Auto • Property Coverage • Machinery Coverage • Aircraft Hull and Liability • Worker’s Comp 8. The District also forms part of the South San Joaquin Valley Mosquito and Vector Control Joint Chemical Service Plan, which allows for savings on all district chemical purchases. 9. Over the past few years the District has purchases of replacement vehicles through the California Multiple Award Schedule (CMAS), which has saved the District up to one-third of the price per vehicle purchased. Through its participation in joint powers authorities and joint purchasing agreements the District is obtaining insurance and chemicals at a high level of cost effectiveness. Coordination with State agencies, such as the State Center for Vector-borne Disease Research UC Davis, California Mosquito and Vector Control Association and the State Department of Public Health, provides the District with, timely cost effective testing of the District’s mosquito pools collected, and dead birds collected for Mosquito-Borne viruses. The district will continue to work with all agencies to create a more effective and cost effective agency. 5) Accountability for Community Service Needs, Including Governmental Structure and Operational Efficiencies 1. A 6-member board of directors governs the Tulare MAD. Members are appointed by the Tulare County Board of Supervisors and the City Councils of Tulare and Visalia. 2. Audrey Dooley, Charles Pitigliano, Robert Clark and Clyde Stagner are Board of Supervisors appointees. Patrick Nunes is a City of Tulare appointee. The City of Visalia’s appointee position is vacant at the moment pending the City of Visalia appointing a Trustee for their area. 3. The Board meets on the 2nd Tuesday of each month. Regular meeting time is 1:00 pm and these meetings are held at the district’s Mefford Field facility. 4. Public hearing notice is posted at the District office and published in the Tulare Advance Register. Agendas are also posted at the District facility. 5. All board meetings comply with the rules and regulations of the Brown Act. 6. The District is divided into 4 zones and a certified vector control technician is assigned to each area to conduct the full range of mosquito control services as needed. During the height of mosquito season 3 additional technicians are hired. 7. Part of the District’s integrated pest management (IPM) includes public outreach and resident education consisting of: • Handouts mailed to land owners and residents informing them of steps they can take to eliminate mosquito breeding sources. • Presentations to community groups upon request. • Published information of immediate threats in the Visalia - Times Delta and the Tulare - Advance Register. 8. The District’s Annual Operational Report provides detailed information regarding revenue sources, expenditures, service requests, surveillance results and acres treated. The report is prepared by the district manager on an annual basis and is reviewed by the District’s Board of Trustees. The report is available to the public upon request 9. The District responds to service request from residents living within the District and as necessary in bordering areas if they are not serviced by an existing District. 10. Residents in the District’s service area and other interested parties can refer to the District’s web site, tularemosquito.com for any information regarding District operations. In addition they can also gain information from the CA Department of Public Health Services web page, westnile.ca.gov regarding sample test results for Mosquito-Borne Virus testing for all of California including the TMAD District. The district’s phone number is also in the current Tulare telephone directory listing. 11. District personnel are licensed through the CA. Department of Public Health through an MOU with the CA. Department of Pesticide Regulation. Personnel are required to pass an initial exam for licensing and receive annual continuation training through the CMVCA. 12. District Positions: Executive Management Professionals Operational Full-Time - 1 - 4 Part-Time - - - - Seasonal - - - 3 Contract - - - - Professional staff are trained and certified to test samples for various viruses. This is service is provided by the University of California’s Kearney Center. Operational employees spray, set traps, extract samples, etc. 13. The California Department of Public Health- Mosquito-Borne Virus Surveillance and Response Plan governs the District’s activities including threat levels and response. The District complies with all public hearing legislation and provides notice to affected parties of public hearings though newspapers of wide circulation in the area and makes all information available upon request. In addition the District’s web site tularemosquito.com is available to view information regarding the District. The District ensures that its personnel maintain an appropriate level of knowledge regarding mosquito abatement techniques through State certification programs and State agency continuing education programs. District management has indicated that public education presentations are done by request and that a staff person is designated and trained for such presentations. 6) Other Matters Related to Effective or Efficient Service Delivery, As Required by Recommendation: As mentioned previously in this MSR the District’s service area includes the southern portion of the City of Visalia. This service area is an integral part of the District’s financial base. The Delta Vector Control District (DVCD) and TMAD share a common boundary along this portion of Visalia and the DVCD has indicated that they have been responding to service calls within this area for several years. The DVCD additionally requested that LAFCO conduct an MSR of both districts to determine which is better equipped and trained to provide service to the subject territory. After conducting an MSR analysis for each district, LAFCO Staff determines that each district possesses adequate financial resources, staff and equipment to provide service to the area within their respective boundaries, now and in the future. Accordingly, LAFCO Staff determines that there is no need to change the boundaries of either district and that doing so could threaten TMAD’s financial ability to provide effective service to its remaining customers. It is thus recommended that County mosquito abatement district boundaries remain the same and that the Delta Vector Control District forward all service calls it receives from within TMAD boundaries to TMAD, unless otherwise prescribed by an agreement between the two districts. 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