Resources have not kept pace with Hawaii’s rapidly aging population when it comes to ensuring the health and safety of residents living in long-term care facilities, according to health officials and state budget documents.

There’s only one paid ombudsman and a shrinking number of inspectors to oversee more than 1,700 nursing homes, adult residential care homes, community care foster family homes and other types of facilities that provide care and services to more than 12,300 people.

But that could change this year. State lawmakers will be deciding in the next couple weeks whether to approve additional funding and positions for the Department of Health.

Long Term Care Ombudsman John McDermott testifies about his office is now a staff of 1 person, him. McDermmot calculated on a 50-week schedule, he would have inspect 48 care homes a a day. 4 feb 2016. photograph Cory Lum/Civil Beat
State long-term care ombudsman John McDermott tells House lawmakers that his office is now a one-man show during a February hearing on a bill to beef up his staff. Cory Lum/Civil Beat

“Unfortunately, there are instances of poor quality of care, violations of civil rights, and even abuse which occasionally come to attention,” said Eldon Wegner of the state Policy Board for Elder Affairs.

“These residents are usually powerless to protect themselves,” he said. “Thus, the best protection to assure quality of care and respectful treatment of residents is to provide access to outside monitoring.”

Gov. David Ige has asked the Legislature for seven more inspectors and $460,000 in funding so the department’s Office of Health Care Assurance can keep up with the increasing workload in certifying and licensing the facilities.

The administration also requested three ombudsman specialist positions and $300,000 in funding for the long-term care ombudsman’s office, which John McDermott has headed since 1998. When he started, there was a staff of two.

“It’s more important than ever,” McDermott said. “We’re the only state in the country where we have one ombudsman.”

Rep. Dee Morikawa, who chairs the House Human Services Committee, removed several provisions of the care home omnibus bill when it was before her.
Advocates for the elderly told Rep. Dee Morikawa, who chairs the House Human Services Committee, that more positions are needed to beef up state oversight of long-term care facilities. Cory Lum/Civil Beat

The Older Americans Act, passed by Congress in 1965, calls on the ombudsman to conduct quarterly visits, investigate complaints and otherwise “protect the health, safety, welfare and rights of the residents.”

“Without these three additional positions, I will barely be able to cover Oahu,” McDermott told the House Human Services Committee, chaired by Rep. Dee Morikawa, at a February hearing on a bill to provide the positions.

“The neighbor islands will never see me or have access to ombudsman services,” he said. “This just isn’t fair to our kupuna and their ohana.”

To meet the quarterly visit requirement, McDermott said he’d have to visit 28 facilities a day. 

“I’m fast but not that fast,” he said.

McDermott pointed to The Institute on Medicine’s recommendation that states have one full-time paid long-term care ombudsman for every 2,000 residents.

“Hawaii just has me,” he said, “for 12,340 residents in 1,702 facilities spread over six islands.”

With three more positions, he said he could handle Oahu and then there would be one for Kauai, the Big Island and Maui.

His office currently relies on trained volunteers, but he said they come and go.

“You really need a staff person; someone who will be there year after year,” McDermott told the House committee.

Silver Tsunami

By 2020, one in four Hawaii residents is expected to be over 60 years old, according the the Hawaii State Plan on Aging. The plan, which is updated regularly, currently covers the period of Oct. 1, 2015, to Sept. 30, 2017.

“The growing number of older adults is likely to put a severe strain on the State’s resources for (Long Term Supports and Services),” according to the plan.

Hawaii’s senior population is growing four times faster than the state as a whole, which now has 1.4 million residents, according to U.S. Census Bureau data.

Senate Ways and Means Chair Jill Tokuda, left, and House Finance Chair Sylvia Luke ask the mayors questions.
Senate Ways and Means Chair Jill Tokuda, left, and House Finance Chair Sylvia Luke will be weighing requests for more health inspectors and ombudsman positions with many other demands for state resources. Cory Lum/Civil Beat

It’s unclear what the House and Senate want to do as far as funding new positions for the long-term care ombudsman’s office. It’s still on the table, but the amount of money has been blanked out.

A joint panel of House and Senate lawmakers are expected to negotiate the final numbers but they’ll need approval from their respective money committee chairs, Rep. Sylvia Luke and Sen. Jill Tokuda. They’ll be balancing that request against myriad other demands for resources in the state’s $13 billion overall budget for next fiscal year, which starts July 1.

The bill to just fund the three ombudsman positions died earlier this year after Luke did not give it a hearing in her Finance Committee. But Sens. Roz Baker and Suzanne Chun Oakland rolled the request into a broader bill to fund various programs and positions for the elderly and disabled.

That measure, House Bill 1878, cleared the full Senate on Tuesday and is headed back in its amended form to the House.

Lawmakers Lukewarm On Inspectors

Ige’s proposed budget, which he submitted to the Legislature in December, included funding for seven new positions for certification and licensing for the Office of Health Care Assurance, headed by Keith Ridley.

The House reduced that to three positions when it took up the budget in March. The version of the budget the Senate passed Tuesday includes five positions. A compromise, to be hammered out later this month, could mean four positions — but it’s also possible that completely unrelated funding requests could trump that and leave the department unchanged.

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 Office of Health Care Assurance has gone from 12 inspectors to 10. During the same period, data shows the number of inspections also dropped.

Dept of Health Keith Ridley listens as Sen Thielen questions him in Capitol Room 16 on care home reports being made public with up to 2 month delay.
Keith Ridley, head of the Office of Health Care Assurance, has said more inspectors would definitely help. Cory Lum/Civil Beat

The Office of Health Care Assurance’s State Licensing Section also has seen a drop in inspectors — from 12 in 2010 to 10 this year — surveying the adult residential care homes 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.

There are almost 500 ARCHs throughout Hawaii. Most of these family-run homes 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.

The state has a contract with Tennessee-based Community Ties of America, which has a local office in Kaneohe, to license and inspect more than 1,100 community care foster family homes. This type of facility, created to serve residents on Medicaid, has a maximum of three clients each.

Silver Lining?

A bill to require unannounced inspections of long-term care facilities, which has become the national standard, could be a saving grace, McDermott said.

Lawmakers are debating whether to establish the new mandate. The measure has cleared the House and Senate, but the final details have yet to be worked out in a joint conference committee. It’s a time near the end of the legislative session when bills sometimes die without much of a reason, though outside pressure on lawmakers is often blamed.

With unannounced inspections required, McDermott said, the department could improve the standard of care at the facilities by keeping the operators on their toes. Ridley’s office currently gives them a heads up before coming to do the annual relicensing or recertification inspection.

94-102 Hula Street. Jennifer Polintan residence for Nathan Eagle story. 27 july 2015. photograph Cory Lum/Civil Beat
The Hula Street home in Waipahu where Nona Mosman received care. She was found with bed sores, and later died as a result. The state closed the business and the caregiver was convicted of manslaughter. Cory Lum/Civil Beat

The mandate may also eliminate the need to do unannounced visits, a less-thorough inspection that the department is required to do for certain facilities once a year in addition to the announced licensing inspections.

If the licensing inspection is unannounced, McDermott said the department could potentially halve the number of trips inspectors have to make to the facilities. The department supports unannounced inspections.

The long-term care industry generally opposes unannounced inspections. Care home operators have told lawmakers that they need to know when inspectors are coming so they can be sure to be home and have all the paperwork in order.

“The bad homes essentially have nothing to fear,” McDermott said. “The state is realizing our population is aging rapidly, and there’s no desire to shut down homes.”

The department generally inspects the facilities, notes deficiencies and then works with the operators on a plan to correct whatever they got dinged for. Only in extreme circumstances are facilities forced to close.

That happened after social workers found 86-year-old Nona Mosman with softball-sized bed sores in the spring of 2013.

Mosman’s primary caregiver, 36-year-old Jennifer Polintan, was convicted of manslaughter for failing to provide the proper care. She was working another full-time job and left Mosman in the care of her father, Francisco Polintan, who was unqualified to tend to her needs.

In that case, the announced inspections failed to uncover any wrongdoing. It was only after a complaint was made that an unannounced visit was conducted. Mosman was removed from the home but it was too late.

“We’re not finding out who’s making mistakes if we keep telling them when we’re coming,” McDermott said.

Rep. John Mizuno has said the vast majority of long-term care facilities in Hawaii do an excellent job, but the bad ones need to be weeded out.

The industry has also opposed posting the inspection reports online, which the department is now required to do on its website, thanks to a law passed in 2013.

But the department has struggled to comply with the posting requirement. The governor asked the Legislature to fund a position to post the reports, but the neither the House nor the Senate versions of the budget included it.

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