Many of Hawaii’s adult care homes are operating without a valid license or with a license issued so quickly the licensing requirements weren’t fully completed, a searing, inaugural audit of the Department of Health’s Office of Health Care Assurance has found.

Moreover, the agency — which is charged with ensuring the safety of adult care homes — doesn’t enforce its own rules which is probably why the OHCA hasn’t issued a termination notice or even a fine in the last 10 years, the State Auditor said.

The audit, issued Thursday, examined 214 adult care homes and found about half had an expired license or one issued in haste.

Care homes were often relicensed before OHCA accepted a plan of correction from the leadership of homes found to be noncompliant. In some cases, the program relicensed homes before an inspection was even conducted.

The audit concludes that the license renewal process for Hawaii’s almost 500 care homes for senior residents is undisciplined and disorganized, operating with no internal timelines or deadlines for steps in the relicensing process.

A single application for relicense often takes more than six months to complete, according to the audit. In one case, OHCA took three years to notify a care home that its plan for correcting noncompliance issues was inadequate.

“According to the licensing secretary,” the audit states, “paying the office’s bills and P-card payments and reimbursing staff travel and mileage were higher priorities than processing and formatting inspection packets.”

The audit also found that OHCA does not make it standard practice to do follow-up visits to care homes to ensure the correction of deficiencies, such as mislabeled medication, wrong dosages given or medication administered or discontinued without a physician’s orders. Furthermore, there are no consequences for care homes that do not correct these errors.

Repeat deficiencies that did not affect the relicensing process in 2016 and 2017 include records of improperly administered medication, residents left alone or with an unauthorized substitute caregiver, unsecured toxic chemicals, cobwebs on the walls and ceilings, and the absence of a schedule of resident activities.

“We found that OHCA neither ranks specific care home deficiencies according to severity (e.g., threats to residents’ welfare) nor does it have guidance on the number of deficiencies that would disqualify a care home from renewal,” the audit states. “For instance, is an inattentive or absent caregiver a more serious deficiency than a faulty fire alarm or mislabeled medicines? Are 25 deficiencies too many? Are 30?”

Health Director Bruce Anderson said in a prepared statement Thursday that OHCA is improving its management oversight procedures and is on track to complete all annual inspections in 2018. Gov. David Ige appointed Anderson as interim health director in May, replacing Virginia Pressler effective June 1.

“Understandably, some may conclude from this audit that those in adult residential care homes were at risk and unsafe in 2016 to 2017,” Anderson said. “However, it is important to underscore that any risks to the safety, health and well-being of those in adult residential care homes are immediately investigated and appropriate action is taken. Further, significant improvements in operations have been made during and since the audit period.”

Notably, the audit concludes that the agency appears to be more supportive of keeping the homes up and running, rather than protecting the health and well-being of the residents.

OHCA Chief Keith Ridley acknowledged in conversations with auditors that the agency’s culture places importance on not disrupting the normal operation of care homes, according to the report.

“At what point do we say, ‘You’re so bad, we are not going to renew your license, and the residents need to move somewhere else?’” he asked during an interview with auditors.

Ridley said that since he was hired in 2008 he has not created any policies or standard procedures to guide license issuance, relicensing or the administering of fines or suspended and revoked licenses. He told auditors that the agency was in the process of developing them, but he could not provide a reason why they have not yet been done.

Ridley leads the handling of licensing and inspections for 1,699 facilities that provide 12,657 beds. Some are larger nursing homes, providing care for dozens of residents, but many are smaller facilities serving just a few clients.

The audit’s scope was limited to the agency’s Adult Residential Care Homes Program, which includes 497 homes. It examined the agency’s actions on behalf of the program in 2016 and 2017.

Beyond the scope of problems highlighted in the audit, a growing number of long-term care facilities for the elderly and disabled have “gone rogue,” operating in the shadows without a license or state oversight, according to industry representatives, state lawmakers and health officials who spoke out about the problems at a legislative hearing this past January.

Inspectors have been denied entry into homes, there have been allegations of deaths linked to the transfer of patients to illegal facilities and an underground pipeline of referrals has persisted with high headhunter fees, they said.

The situation has gotten to the point that some health officials are worried that Hawaii’s rapidly aging population may end up with unsafe options for their care.

Then, in July, a new law gave OHCA stronger enforcement tools for dealing with unlicensed care facilities, including a provision that makes it a misdemeanor to interfere with a care home investigation.

But the audit appears to question OHCA’s ability to utilize these new tools.

“If OHCA is unable to adequately oversee its licensed care homes,” the audit asks, “how can it be expected to police unlicensed ones?”