When the federal government and states from Oregon to North Carolina inspect long-term care facilities, their inspectors arrive unannounced — so they can see the homes’ conditions as they are.

Not Hawaii. Its inspectors give homes days, weeks, even months of advance notice.

The head of the agency overseeing the homes says he’d like to make inspections tougher by making them unannounced. But neither he nor the Health Department have any plans to actually do so — even though critics say that the agency could begin unannounced inspections of many homes today.

Health officials here say they need more inspectors and more funding. And a Civil Beat review of Health Department data for the past six years shows that a shrinking number of surveyors increasingly are stretched to inspect the more than 1,700 long-term care facilities in Hawaii.

Hokulaki Senior Living LLC walkers and wheel chairs. care home elderly. 14 aug 2015. photograph Cory Lum/Civil Beat

Walkers and wheelchairs are parked outside rooms for elderly residents at Hokulaki Senior Living, an adult residential care home in Kaneohe.

Cory Lum/Civil Beat

“Unannounced visits are the better way to go,” said Keith Ridley, chief of the department’s Office of Health Care Assurance.

“Providers need to be aware that compliance with the law in safeguarding their residents isn’t just something that’s episodic or at a point in time when they know we’re coming,” he said.

Health officials, national experts and state lawmakers have said that mandating unannounced inspections would significantly improve the overall accountability of the care home industry and potentially save lives.

Nona Mosman died in 2013 after social workers discovered the 88-year-old with softball-sized bed sores at a three-bed community care foster family home in Waipahu.

Her primary caregiver, Jennifer Polintan, was working another full-time job and leaving Mosman in the care of her father, who was unqualified to tend to her needs.

Routine announced inspections failed to uncover this problem. It took a complaint to trigger an unannounced visit, but by that time, it was too late.

Polintan is now in prison after being convicted of manslaughter, and the business has been shut down.

Many states require unannounced inspections by law, but it doesn’t look like Hawaii will join their ranks anytime soon.

“We want to,” Ridley said. But, he added, “It’s sort of a lower priority.”

The Health Department is also gearing up to run the state’s new medical marijuana dispensary program and dealing with a backlog of 1,000 patients who have applied for medical marijuana cards. It’s also planning to ask for $160 million next session to expand the Hawaii State Hospital.

What It Would Take

The laws covering oversight of different types of care facilities vary. For example, the Office of Health Care Assurance could act on its own to begin unannounced inspections of the more than 1,100 community care foster family homes it regulates. These homes have a maximum of three clients each.

But Ridley said that for the office to conduct unannounced inspections of other types, including adult residential care homes, or ARCHs, which can have up to eight clients, the Legislature would have to change the law. 

There are almost 500 ARCHs throughout Hawaii. Most are certified for up to five clients, but some can have up to eight and provide care comparable to that found in institutional nursing homes.

Ridley noted that the law states, “the department shall conduct unannounced visits, other than the inspection for relicensing.” He said the latter half of that provision bars his office from conducting the annual or biannual inspections for relicensing without giving ARCH operators a heads up that the inspectors are coming.

For surveyors, “visits” are very different from “inspections.” Inspections can last for several hours, and surveyors file written reports on the conditions they find that become publicly available. The visits are typically much shorter, sometimes lasting half an hour or less.

“We won’t know until we ask. Unfortunately, we don’t have any plans to ask.” — Keith Ridley, OHCA chief

Advocates for the elderly say the unannounced visits are generally far less thorough than the inspections for relicensing. 

The state’s long-term care ombudsman, John McDermott, has long fought to make unannounced inspections mandatory.

He said a provision in another part of that statute seems to give Ridley the ability to send inspectors in unannounced without any need to change the law.

Further down, the statute says annual inspections for relicensing shall be conducted with notice, “unless otherwise determined by the department.” McDermott said the agency could cite that and start conducting unannounced inspections for relicensing.

Some care home operators said they are OK with the state doing unannounced visits; but for decades, industry groups have fought every move to require unannounced inspections for licensing.

Hawaii care-home operators have said they need to know when the inspectors are coming so they can get their paperwork in order and make sure they are home with their clients and not out running errands like picking up pills. They’ve also cited privacy concerns.

Lilia Fajotina, president of the Alliance of Residential Care Administrators, which represents ARCH operators statewide, has said the current inspection system works well.

“Whenever we do any kind of unannounced-visit legislation it’s usually met with resistance.” — Sen. Jill Tokuda

In May, she received noticed from the state that the Waipahu care home she runs would be inspected on a Wednesday in November. She considers that to be fair warning to prepare things like criminal background checks, medication schedules, updated CPR certifications and tuberculosis clearances for inspectors to review.

McDermott said that nursing homes initially objected to the federal government’s decision to mandate unannounced inspections decades ago. But he noted that it didn’t shut down the industry and the standard of care has improved. He believes the same would happen for the care home industry here.

“The inspections now are really kind of shibai; they’re not really inspections,” he said. Shibai, in Japanese, means play-acting.

Senate Ways and Means Chair Jill Tokuda, who served on the state Policy Advisory Board for Elderly Affairs in the early 2000s, said the issues in this longstanding debate over the nature of inspections haven’t changed.

“I know from the past, whenever we do any kind of unannounced-visit legislation it’s usually met with resistance,” she said.

But as of now, the department has no plans to request a change in the law or revise its own policy.

Asked about the chances of getting a bill through the Legislature to require unannounced inspections, Ridley said, “We won’t know until we ask. Unfortunately, we don’t have any plans to ask, at least for the ARCHs.”

Nor do officials plan to change the policy internally for other types of facilities.

“It’s the kind of thing that we would clearly prefer to have implemented for all the providers that are under our responsibility,” Ridley said. But “we don’t have any plan at this point.”

Senator Jill Tokuda, Chair of Committee on Ways and Means and Representative Sylvia Luke, Chair Committee on Finance during informational briefings from the Office of the Governor, Office of the Lt. Governor and Department of Budget and Finance held at the Capitol auditorium. 6 jan 2015. photograph Cory Lum/Civil Beat

Sen. Jill Tokuda, left, and Rep. Sylvia Luke, who chair their respective chamber’s money committee, have significant influence over the Health Department’s budget.

Cory Lum/Civil Beat

The community care foster family home program, which was created to take advantage of a Medicaid waiver allowed by federal law, was under the Human Services Department until the Legislature transferred it to the Health Department in July 2014.

Ridley said the state has had a contract for years with Tennessee-based Community Ties of America, which has a local office in Kaneohe, to license and inspect these facilities. He said Human Services directed CTA to do announced visits for community-care foster family homes and almost 40 adult day care centers, another type of facility the state regulates. The Health Department has kept that practice in place.

“That’s something that could be changed,” Ridley said. “If it’s changed, we’d want to make sure at a minimum it’s done in the regulations — so it’s a rewrite of the administrative rules.”

Rep. Sylvia Luke, who chairs the House Finance Committee, said lawmakers could unilaterally take on the issue of mandating unannounced inspections. But she said they generally prefer to let the departments prioritize their needs, particularly since the Legislature is only in session for four months.

“We don’t know what’s happening with little agencies unless they come to us,” she said.

Doing More With Less

The Health Department data Civil Beat obtained in response to an open-records request shows a proliferation of community care foster family homes in particular. Such homes are subject to fewer restrictions than some other types of facilities, even though they can provide clients a level of care comparable to nursing homes.

The industry has grown steadily over the past five years; the number of inspectors hasn’t.

Five people are responsible for inspecting the homes on an annual or biannual basis, depending on how well the home is operating.

There are now 1,135 community care foster family homes in Hawaii, up from 1,068 in 2010. Each home has up to three clients, of whom one can pay out of his or her own pocket and the others through Medicaid.

The contract with Community Ties of America has been unchanged for the past five years — $811,524 for community care foster family homes and $50,000 for adult day-care centers, according to the Health Department.

Ridley said his office is looking into whether it would be more cost-effective to terminate the contract and do oversight in-house like it does for other types of facilities. At a minimum, he wants to bring the level of regulation for community care foster family homes on par with similar types of facilities.

Office of Health Care Assurance Chief Keith Ridley is seen here testifying before lawmakers last year.

Office of Health Care Assurance Chief Keith Ridley is seen here testifying before lawmakers last year.

Cory Lum/Civil Beat

But those are not the only type of long-term care facilities for which inspectors are increasingly being stretched thin.

There are also fewer inspectors to survey the 50 skilled nursing facilities statewide; these are facilities that can house dozens or more elderly clients apiece.

Over the past five years, the Medicare Section of the department’s Office of Health Care Assurance has gone from having 12 inspectors to 10. During that same period, the data shows the number of inspections also dropped.

In 2010, 12 inspectors surveyed 50 nursing facilities — all of which were done unannounced because they were conducted in conjunction with federal Medicaid licensing re-certifications that forbid advance warning.

Last year, 10 inspectors conducted 32 inspections. But with the budget increasing from $772,137 in 2013 to $987,125 in 2015, health officials said they expect to survey all 50 this year.

The Office of Health Care Assurance also has seen a drop in inspectors to 10 this year, from 12 in 2010. 

They are responsible for surveying the ARCHs and roughly a dozen assisted-living facilities, which range in size from 67 beds at Hiolani Assisted Living Center at Kahala Nui to 431 beds at Arcadia Retirement Residence in Honolulu.

The budget for inspectors to survey these facilities dropped from last year by 5 percent to $838,584.

Surveyors plan to do 537 unannounced visits and 493 announced inspections of ARCH facilities this year, according to the Health Department. Ten inspections are planned for assisted living facilities, with seven being announced.

The Health Department’s budget request includes funding for additional surveyors and administrative support staff “in order to be better capable of inspecting various health care facilities under the department’s statutory and regulatory authority,” spokeswoman Janice Okubo said.

The dollar amounts are being discussed internally, she said, declining to disclose the exact figures.

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