State lawmakers gathered at the Capitol on Thursday to hear health regulators respond to a searing audit that portrayed the agency trusted with protecting elderly residents of Hawaii’s adult care homes as all but dysfunctional.

The state audit’s primary takeaway is that many of the adult care homes have been operating without a valid license or with a license issued in haste despite any assurance that outstanding violations had been corrected.

The audit found that the Department of Health’s Office of Health Care Assurance doesn’t enforce its own rules  and hasn’t issued a termination notice or even a fine in the last decade. The audit concludes that the agency appears to be more concerned with keeping the homes in business, rather than protecting the health and well-being of the residents.

DOH Interim Director Bruce Anderson told members of the Senate Committee on Commerce, Consumer Protection and Health and the House Health Committee that OHCA has already made a swift turnaround, implementing revised policies and speeding up inspections, while transitioning to a more efficient, all-digital record keeping system.

“There has been remarkable change and I can only attribute it to having some new staff, having some new resources,” Anderson said.

All told, the agency in 2018 has so far completed annual relicensing inspections at 398 of the state’s 460 licensed care homes, Anderson said. About 15 percent of those homes were not relicensed in a timely manner.

He said the agency is on track to complete the remaining 62 inspections before the end of December and has a plan to further improve its performance in 2019.

“We have a good story to tell going forward,” Anderson said. “I’m not going to make excuses for the past, but I think the improvements that I’ve seen in six months, and even before that, have been dramatic.”

Miracles?

The prospect of such a fast turnaround raised the eyebrows of Rep. Bertrand Kobayashi.

“The picture that the auditor paints and the picture that you paint is so different, it’s bewildering,” Kobayashi said.

“I don’t know who to believe,” he said. “Apparently, according to your story, something has happened fairly miraculously in the last 12 months that has changed the picture that the auditor paints. And in my conception of government, miracles don’t happen.”

State Auditor Les Kondo said he couldn’t verify the improvements the OHCA claims to have made in the 11 months since he found the agency operating without any policies or standard procedures to guide issuing licenses, relicensing or the administering of fines or suspended and revoked licenses.

”Maybe a miracle happened,” Kondo said. “I don’t know.”

As an example of the agency’s flawed record-keeping less than a year ago, Kondo pointed out that the agency had no records for six care homes in 2017. The agency told auditors that four of these homes without records had shut down, he said. But Kondo said he later found that four of them still had an active license.

OHCA is required to provide the auditor a report at the end of next year detailing how the agency has improved its procedures. The state will then conduct a follow-up audit in 2020.

Anderson and OHCA Chief Keith Ridley also agreed Thursday to provide the committee members with periodic reports tracking the agency’s progress, with the first report due in April.

More immediately, they pledged to provide lawmakers with a timeline for implementing new policies and procedures.  

For example, the agency still has no policy regarding how it addresses public complaints against adult care homes and their staff members. It has no policy to guide how penalties should be levied against care homes with violations, such as mislabeled medication, wrong dosages given or medication administered or discontinued without a physician’s orders.

“One of the things we are going to do is streamline our process,” Ridley said. “Traditionally we have tried to work with the facility to make these corrections. A lot of that is going to be eliminated. The facility is just going to have to do it, or close.”

The audit’s focus was limited to the performance of the agency’s Adult Residential Care Homes Program in 2016 and 2017, when there were 497 homes.

Other problems were identified at a hearing last January that go beyond what was detailed in the audit.

Lawmakers heard testimony that an increasing number of care homes for the elderly and disabled are beginning to bypass the licensing process, operating surreptitiously without any state oversight, and there have been allegations of deaths linked to the transfer of patients to illegal facilities.

With steady growth of Hawaii’s elderly population, some health officials are growing concerned about the safety of the facilities vying to house them.

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.

Lawmakers added to OHCA’s enforcement toolkit, granting the agency the power to conduct unannounced visits to check on care home compliance. The agency is currently required to visit each care home once a year in addition to the annual inspection. But the visits are scheduled with the care homes in advance.

The audit was skeptical about OHCA’s ability to effectively use these tools.

“OHCA needs to re-center itself,” Kondo said. “It needs to re-examine its statutory mission and reprioritize all of its policies and procedures and actions around that statutory mission, which is to protect the health and safety and welfare of the care home residents — not to continue the operation of the care homes themselves.”