I hope this time it makes a difference. The flaws in the state’s licensing of adult care homes outlined in by the state auditor are clearly not new issues, but the good news is they are all fixable.

I became the State Long Term Care Ombudsman in 1998 after working for nine years in two different nursing homes as the Director of Social Services. The federal Nursing Home Reform Act of 1987 mandated that all nursing home annual inspections be “unannounced” so it wasn’t a big deal to me, that’s all I knew, but some of the staff who had started years before me took a while to accept this change.

Eventually every nursing home got used to it and realized it resulted in better, more consistent care.

When I became the ombudsman I was shocked to discover our Department of Health is required by state law to notify adult residential care homes (which is also their practice for assisted living facilities and community care foster family homes) when they are coming for their annual inspections.

How do you find anything wrong if you tell folks when you are coming? No other state does this. To me it was just “paper compliance” offering our vulnerable seniors no protection at all.

The Hawaii Department of Health oversees the office that is responsible for inspecting and licensing care homes. Cory Lum/Civil Beat

Marilyn Seely was then director for the Executive Office on Aging (and my boss) and we went to discuss our concerns about this to then Department of Health Director Bruce Anderson. He was not aware of this practice and agreed with us that it needed to change.

On Nov. 26, 1999, Dr. Anderson sent out a “policy directive” to the Adult Residential Care Home industry notifying them that “all inspections pursuant to licensing activities, including licensing, follow-up visits, and complaint investigations shall be unannounced.” Please note the word “shall,” not “may.” Words matter.

Ugly Politics

We thought we had won this battle but this policy directive never went into effect. The ARCH industry went running to their favorite legislators and to then Gov. Ben Cayetano and Dr. Anderson’s policy directive quietly disappeared. Ugly politics again.

Despite this set back we didn’t give up and recruited AARP’s help in the following election cycle. They made “unannounced inspections” one of their three top priorities. I was disappointed that Mazie Hirono, when asked about this issue at a public debate at the State Capitol auditorium, stated she supported the current status quo. Linda Lingle, however, stated she would support unannounced inspections — and won over many senior advocates in the audience.

Lingle was elected governor and we happily waited for Dr. Anderson’s policy directive to be enforced. And once again, it never happened. Instead of an “unannounced” annual inspection, Lingle continued the current policy but, as a concession, also added an annual “unannounced” visit. This meant she doubled the surveyors’ workload without doubling their staffing … and they have fallen behind in the mandatory inspections ever since.

How do you find anything wrong if you tell folks when you are coming? No other state does this.

The “unannounced” visits reveal which homes are providing substandard care, but these visit reports are not accessible to the public. The department knows better than anyone, because of these visits, which homes really should be closed down but if they do close down a home, where do they place the residents being displaced?

And since some of these homes will sue, the department needs to make sure they did everything by the book and all their documentation is in order. It’s so much easier to just pretend not to know.

We’ve spent close to 20 years trying to get the governor, the Legislature and the Department of Heath to require real, honest “unannounced” inspections. Get rid of the annual visits so state surveyors can focus on the inspections. Gov. Neil Abercrombie signed that law but it’s still being fought by the Department of Health.

Read the Department’s 2018 Report to the Legislature where they recommend “Delay by two (2) years the effective date of conducting unannounced annual inspections until July 1, 2021, while more data is gathered on outcomes of unannounced visits. Continue with the current procedure for annual inspections for purposes of license and certification renewals.”

This same report also states “The department shall conduct unannounced visits with greater frequency in addition to the one (1) mandatory unannounced visit as currently allowed in statute. This may require additional staffing resources or, without additional staff, would require prioritizing unannounced visits higher than announced annual inspections.”


Failing a “visit” has no consequences and the public can’t review these visit reports prior to placing a loved one in that home. This is backward thinking. We need real unannounced inspections. Drop the visits so you have sufficient staffing to do the job correctly.

Gov. David Ige has attended every Older Americans Month luncheon since being elected and has made a commitment to protect our most vulnerable seniors. Twenty years ago Dr. Anderson tried to improve the care and protection of our seniors but he was unsuccessful. He now has a second chance and with the State Auditor’s Report, he has the documentation needed to make substantial improvements.

Let’s get this job done!

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