For most senior care homes, strict no-visitor policies have been in effect for more than a month. Not even family members are allowed to see their loved ones in person during the COVID-19 pandemic.

But the state health department is still sending out inspectors on sometimes unannounced visits — and they’re keeping their shoes on, alarming some care home operators.

Several care home operators and representatives are wary that surveyors could unknowingly introduce the virus and want them to wear more protective gear when entering care homes. Others would prefer the state suspend its visits entirely.

“DOH is supposed to be the ones protecting us and everybody because we don’t know where the virus is coming from and how it’s going to be transmitted,” said Maribel Tan, president of the Adult Foster Homecare Association of Hawaii. “When they come into our houses not wearing PPE and not covering their shoes it kind of defeats the purpose of them coming and checking.”

Keith Ridley, head of the state Office of Health Care Assurance, says certain inspections will continue and they’re important, especially during a pandemic. Surveyors also wear masks, he said.

DOH, which recently fined an unlicensed illegal care home $88,000, has the legal right to conduct random inspections. A 2019 law requires annual unannounced inspections of nearly 2,000 care facilities for the elderly and disabled.

Those surprise visits began in July 2019 and marked a significant shift for the department after more than two decades of lax oversight.

Surprise Check-In

When three inspectors showed up at Manoa Senior Care doors for a routine annual inspection earlier this month, Paul Dold, president of the care center, was surprised.

“I was actually shocked last week to find out they were still doing routine inspections, I had assumed the department had decided to stay them,” Dold said.

To limit any possible viral exposure, he asked the surveyors to leave, and they complied. Manoa Senior Care has been in operation for more than two decades, but his request for the inspectors to leave prompted a DOH threat to his license of 25 years, he said.

“The only PPE they were wearing was surgical face masks. They weren’t wearing gowns, booties or gloves,” Dold said. “What I’ve asked them to do is until the stay at home order is lifted, (suspend) these routine inspections. You just can’t be careful enough.”

Dold takes issue with the department’s stance that routine visits are essential. Now, Dold says he’s been going back and forth with DOH to ask them to stop routine annual inspections until the COVID-19 pandemic subsides.  

“I think for me and a lot of people in the industry, it’s a risk versus reward analysis,” he said. “If you’re having additional people come into the home, that’s presenting some degree of risk. Why they are so insistent on not delaying it, I really don’t understand.”

Inspections Will Continue, DOH Says

Ridley says Manoa Senior Care was due for its annual license renewal, and the department is working with the facility to reschedule an inspection.

DOH is continuing to visit care homes for license renewals, inspect new facilities and licensees, investigate complaints relating to COVID-19 infection control, and randomly check in on skilled nursing facilities that have a history of being cited.

When inspectors visit, they wear masks, wash their hands and use hand sanitizer, among other coronavirus-related precautions, he said.

Coronavirus prevention check-ups have been folded into surveyors’ visits. The majority of Hawaii kupuna live in adult residential care homes, assisted living facilities and community care foster family homes, not nursing facilities.

“Everyone has a valid concern. Actually observing that sort of thing is helpful for us to essentially verify that that is part of their infection control and process,” Ridley said.

“It would be entirely appropriate for homes to do the same kind of infection control querying of our surveyors as they would for anyone accessing the home.”

OHCA, which is charged with ensuring the safety of adult care homes, has a contract with Community Ties of America to perform the licensing and certification inspections.

Hawaii is not currently regularly testing the residents of senior care facilities, rather certain patients are referred for testing by doctors if they are believed to have been exposed or begin to show symptoms. The fear is that by the time a case is identified, it could have already spread.

An Associated Press analysis found at least 450 deaths and nearly 2,300 COVID-19 infections have been linked to outbreaks in nursing homes and long-term care facilities across the U.S.

A Sudden Switch To A Shoe Policy

An April 14 email newsletter to local Community Care Foster Family Home operators from Community Ties of America sparked more alarm.

“Effective immediately for safety and sanitary purposes, CTA staff will no longer remove shoes before entering a home,” the letter stated. “This is to protect our staff and the people in your home. The medical community is advising against using disposable shoe coverings.

“We understand the cultural significance and hope you understand that a CCFFH is a business and since we do not remove our shoes upon entering a nursing home, grocery store or any other business we can no longer do so in order to comply with regulatory requirements that govern our employees. We also want to ensure we are not using PPE that other essential workers really need to use.”

The Community Care Foster Family Home program is likened to foster care in a smaller family-like setting for seniors. There are about 800 adult foster care homes in Hawaii.

Cora Cariaga, president of the Big Island Adult Foster Home Operators group, oversees about 140 community care foster family providers. She didn’t like the newsletter’s comparison of the smaller care homes to grocery stores.

“When I received this email from CTA, it really bothered me because it said they can just come inside our house with their shoes on,” she said. “We have vulnerable clients in our homes and we don’t want COVID-19 to be spread in our homes because of their situation. It’s so disgusting that they’d say this in the newsletter. They should have said something with aloha spirit, but they’re just harassing us.”

John McDermott, the state’s long-term care ombudsman, said the announcement did come suddenly to many of the caretakers he works with.

“CTA’s letter makes it sound like it’s just a business, but it’s not just a business, it’s also a home where people live,” McDermott said. “It just came across as very heavy handed, insensitive and very culturally inappropriate.”

Typically there are all kinds of labor law requirements for closed-toe shoes, and those have been the federal labor rules since 1985.  

Community Ties of America declined to be interviewed, noting that it was prohibited to do so by its contract with the state.

The COVID-19 pandemic, Ridley says, had nothing to do with the shoe policy announcement. It was prompted by a review of the guidelines.

“Culturally, we take off our shoes before we go in, and that’s been something we’ve done in Hawaii for decades. It became that habit. We didn’t think anything of it previously,” Ridley said. “Then in looking at the OSHA safety requirements, it was like, ‘oh my, we haven’t been following those requirements.’”

McDermott says the shoe policy switch is very bad timing.

“Why do this now when everyone is looking at our caregivers to be especially cautious about keeping their homes clean and now you want to attract dirty shoes?” he said. “It’s not a consistent message.”

Virologist Dr. Virginia Hinshaw, the chancellor emeritus and professor at the John A. Burns School of Medicine, says studies do show that shoes can carry a lot of bacteria and viruses. Wearing booties would be a simple solution, she said.

“To me the care home operators are doing it to protect their residents and particularly when someone is going place to place.” she said. “They’re trying to be on the far side of cautious, which seems — in this day and age, and considering the population they have in there — that’s a reasonable request.”

National Guidance

The Centers for Medicaid and Medicare Services, which regulates large nursing home facilities — not the smaller types of facilities monitored by Hawaii’s OHCA — issued a memo on March 4 recommending that state agencies temporarily cease certain visits until the pandemic is resolved.

According to the memo, CMS isn’t suspending all state surveys, just particular non-emergency inspections so inspectors may prioritize the most serious threats and quickly respond to complaints and concerns about infection control and abuse. Any enforcement actions already in process will continue uninterrupted. And the state will certify any new providers to “support building healthcare capacity.”

Ridley thinks there’s a misunderstanding of the CMS recommendation. OHCA is not obligated to follow CMS, and its guidelines do not necessarily factor into the health department’s operations.

“We do pay attention to the rationale behind any CMS guidelines and their suspension for conducting certification surveys. But what they’ve also done is prioritize,” Ridley said.

“I think everyone misperceives that CMS is suspending surveys. Well, they did, and they didn’t. It’s a bit of a mix. The emphasis is on ensuring that infection control is being performed appropriately at the different facilities.”

Still, Dold has requested that the state cease its visits temporarily. The current Manoa Senior Care policy is to only allow medical personnel on the premises.

“In the past the licensed inspections have been delayed for staffing issues and other issues I’m not aware of,” said Dold. “They’d send an interim license for a 30-day or 90-day period. I know there was complaining about that, and there had been a change in policy but historically this was common.”

Now, the department is trying to “bridge that gap between culture safety and infection control,” Ridley said.

Ridley said there are internal DOH discussions about how to work out a way to meet both caregiver and federal expectations — how to culturally respect the homes while still meeting infection control rules.

Last week, when Civil Beat inquired again, Ridley said if care home operators offered inspectors booties, gloves or gowns to wear, they would wear them.