State health officials have been inspecting Hawaii’s nursing homes much more frequently, which has helped them score points with the federal agency that oversees Medicare facilities for the elderly and disabled.

But the extra attention on nursing homes has meant less of a focus on home health agencies, dialysis centers and same-day surgery facilities.

The U.S. Centers for Medicare & Medicaid Services evaluated the inspections that the state Office of Healthcare Assurance does of Hawaii’s Medicare facilities over the last year and concluded that the state didn’t meet the minimum standards for quality, frequency and timeliness in eight of 13 categories.

Keith Ridley, who heads the state Office of Health Care Assurance, said the state simply doesn’t have the staff to inspect all the facilities within the time frames the federal government requires.

State Office of Health Care Assurance Chief Keith Ridley says the state has more work to do but has made improvements in its nursing home inspections. Nathan Eagle/Civil Beat

He said CMS basically told state health officials that they needed to start inspecting nursing homes more often or risk losing funds, so the state shifted its only available resources accordingly. The federal government pays 80 percent of the cost of the state’s inspectors.

Ridley acknowledged that more work needs to be done but noted that the federal evaluation also found that the state is making progress in many areas. 

For instance, nursing homes are required to be inspected every 15.9 months. In fiscal 2015, the state average was 28.2 months and 31 of the 45 nursing homes exceeded that standard.

In fiscal 2016, the state average dropped to 17.8 months and only two of the 44 nursing homes had not been inspected within 15.9 months, according to the federal evaluation. But since all nursing homes must be inspected within that time frame, the state still did not meet the requirement.

When the state shifted its attention more to skilled nursing facilities, it diverted resources from home health agencies and other facilities. This chart shows the percent of facilities surveyed each year, including those for skilled nursing; intermediate care and individuals with disabilities; home health agencies; ambulatory surgery centers; and end stage renal disease. Courtesy: Health Department

When it comes to other types of Medicare facilities subject to federal review, the state has struggled to meet numerous requirements in large part because of the direction to focus on the nursing homes, Ridley said.

Of the eight active home health agencies, only four were surveyed and it had been more than three years for two of them. It was similar the previous year. But before priorities changed, the state surveyed all the home health agencies from 2012 to 2014, state health department data shows.

For ambulatory surgery centers, only three of 14 were surveyed.

And of the 16 facilities for people requiring intermediate care or who have intellectual disabilities, the average interval for inspections was 20 months — four months longer than the requirement.

“The unfortunate thing is from a trend standpoint, we have a history of not meeting the performance measures for a variety of reasons,” Ridley said. “The key reason is limited resources — both in the number of positions and in keeping those positions filled.”

There are 12 positions for state health inspectors, called surveyors. Eleven are for nurses and one is for a social worker. Only nine of those 12 positions are currently filled.

“People retire, relocate out of state or just change jobs,” Ridley said. “It’s been difficult for us to get fully staffed and stay fully staffed.”

State health officials say they look for trends in the evaluations they receive from the federal Medicare agency. They see the frequency of inspections for nursing homes improving but note the declining performance for home health agencies and intermediate care facilities. Courtesy: Health Department

Richard Mallot, executive director of the New York-based Long Term Care Community Coalition, has worked for years at a nonprofit whose mission is to improve the quality of care and quality of life for elderly and disabled people in nursing homes, assisted living and other residential settings across the country. He had concerns about Hawaii’s review but noted the limitations of the federal evaluation.

“In my opinion, it appears that the Hawaii Department of Health is, too often, failing to undertake the basic quality assurance activities that are necessary to ensure patient safety,” he said.

State agencies have a basic responsibility to conduct inspections and respond to complaints for nursing homes and other licensed providers in specific timeframes, he said.

Some nursing home inspections, for instance, must take place outside of normal business hours. 

Mallot said the federal evaluation addresses whether the state agency is meeting these basic criteria, but said that “it does not, in any way, get at whether the (state agency) fulfilled its responsibilities to ensure that standards of care and safety are met.”

He also questioned why the state Department of Health has posted on its website an article titled “Hawaii: Best Nursing Homes In The Nation.”

While the state does have the highest percent of top-rated long-term care facilities and prescribes antipsychotic medications at a rate that’s much lower than average, Mallot noted that Hawaii nursing homes have slightly more than the national average of citations — showing that the state is struggling to meet some basic requirements for conducting oversight.

$515,533 In Fines Serves As ‘Motivator’

Other evaluations, which look at the fines that are doled out for violations and the seriousness of the deficiencies, have found Hawaii to be a mixed bag when it comes to nursing home inspections.

When it comes to more serious deficiencies — those providing immediate jeopardy to resident health or safety of — Hawaii is in the upper middle of the pack nationally, according to ProPublica’s Nursing Home Inspect database.

Hawaii averaged 0.29 per home. New Mexico and Kentucky led the pack with 1.5 per home. New Hampshire had the least with 0.1 per home, according to Nursing Home Inspect.

Hawaii’s fines were lower though, in the bottom third nationally. The fines averaged $19,600 per home. Maryland, by contrast, had about the same amount of serious deficiencies per home as Hawaii, 0.35 per home, but led the country in fines at $135,000 per home.

The feds have fined Hawaii nursing homes over half a million dollars over the past three years, CMS data shows. The fines totaled $515,533 for 17 facilities on Oahu, Kauai, Maui and Big Island.

Hale Makua in Kahului, for instance, was inspected Oct. 14, 2016, with a violation in the most severe category, for not ensuring that the nursing home area was free from accident hazards or providing adequate supervision to prevent avoidable accidents. The facility was fined $21,403. 

Ridley said the federal government collects fines when state inspectors find fairly egregious conditions and share that money with the state.

“It’s a motivator for the facility,” he said.

Ridley said even with a few extra inspectors and supervisors, it would take years to bring the state fully into compliance. But he’s not optimistic about getting the additional five positions he’s asking for next year.

“We have a long way to go,” he said.

Still, the improvements in a few of the key areas for nursing homes leaves him hopeful.

“This is an indicator we are turning the corner and doing better,” Ridley said.

Read the CMS evaluations for fiscal 2016 below to see what categories the state met and didn’t meet.


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