Hobbled oversight

FIRST OF TWO PARTS

Budget cuts and other belt-tightening steps taken by the state over the past several years have crippled the ability of inspectors to monitor Hawaii’s nursing homes, federal officials say.

The strain on the system has contributed to the state Department of Health’s failure in four of the past five years to meet a federal standard for properly evaluating the severity of complaints, a key factor in deciding the order of investigations, according to federal data. Only two other states fared as poorly or worse.

The state also has had problems evaluating deficient care, sometimes assessing deficiencies at levels less serious than what was warranted, the officials told the Star-Advertiser.

Senior advocates say the regulatory gaps that persist here indicate that Hawaii needs to put a higher priority on serving the needs of its fast-growing elder population. As the number of Hawaii care facilities, especially non-institutional ones, surges to keep pace with the senior population, advocates question whether the state’s already-strained regulatory apparatus will be up to the task.

"This problem, really, will grow, not shrink, over time," said Cullen Hayashida, who directs Kapiolani Community College’s Kupuna Education Center. "We’ve got to rethink this whole area of inspection and oversight."

Since about 2008, the budget crunch and an increased workload have contributed to the state’s spotty record of launching investigations on a timely basis, federal officials said.

In one case, inspectors didn’t get to a Hawaii island nursing home for about three months to investigate a November 2009 report of a resident found with his hand inside a female resident’s shorts, touching her thigh.

The regulations require investigations for those types of incidents to occur within 10 days, federal officials said.

Steven Chickering, a San Francisco-based administrator for the U.S. Centers for Medicare and Medicaid Services, which oversees federally certified nursing homes nationally and pays the states to monitor them, said a lot of Hawaii’s struggles have to do with a lack of adequate support from the state for inspectors to do their jobs.

Asked whether the regulatory gaps could undermine the public’s confidence in the ability of inspectors to ensure safe environments, Chickering replied, "I think it’s in question."

But he said CMS and the state are working together to make improvements, and that some progress already has been evident. Chickering’s agency also is helping the state make the transition to a new inspection process that is being implemented nationally and is designed to bring more consistency.

Loretta Fuddy, the state’s new health director, acknowledged that the department has had problems meeting certain federal standards in recent years because of the effects from a hiring freeze, retirements, furloughs and other developments.

At one point, about half the inspector positions assigned to nursing homes and other Medicare facilities in Hawaii were unfilled because of retirements and the hiring freeze.

The furloughs, which ended last month, were especially difficult to deal with, Fuddy said.

"There’s no doubt that the furlough situation jeopardized many of the programs within the Department of Health to carry out (their) functions," she said.

But with furloughs no longer a factor, the ending of the agency’s temporary oversight responsibilities for certain Pacific facilities outside the state and a regulatory unit that soon should be fully staffed, the department will be able to meet federal standards, take action on a more timely basis and continue to ensure Hawaii’s nursing home residents receive quality care in safe environments, she said.

"We’re in a better situation today," Fuddy said. "We should see improvements in performance."

She disputed any suggestions that safety is being compromised.

Despite the gaps in oversight, regulators and industry officials tout the quality of care provided by many of Hawaii’s nearly 50 nursing homes.

A significant number are very good and rated highly, said Keith Ridley, head of the department’s Office of Health Care Assurance, which inspects the facilities for compliance with state and federal regulations.

Hawaii is one of only five states in which at least a quarter of the nursing homes have five-star ratings, the highest possible in the federal government’s evaluation system for consumers.

"It sounds hokey, but I think there’s a prevailing sense of caring here" that typically isn’t found on the mainland, said Emmet White, chief executive officer of Arcadia Retirement Residence and chairman of the Hawaii Long Term Care Association. "It’s not whim or caprice."

Because CMS typically pays Hawaii more than $1 million a year to inspect nursing homes, hospitals and other Medicare facilities for compliance with federal regulations, it regularly monitors those efforts.

For nursing home inspections, the agency sometimes will accompany state inspectors to a facility to observe the process and compare results. At other times, it will send its own inspection team to a nursing home after a state team leaves.

Using either method, CMS checks to see whether there are significant differences between what the federal and state inspectors find. Few differences generally means the inspectors see things similarly, a positive sign.

Of the 18 monitoring surveys that CMS has conducted in Hawaii since 2008, it found significant differences in a third of them, including four of the seven surveys in which a federal team did its own inspections.

Finding significant differences in more than 50 percent of the latter surveys is significant, according to Paula Perse, long-term-care branch manager for CMS’ Region 9 office in San Francisco.

One problem that was flagged was the tendency of state surveyors to assess deficiencies at levels less severe than what the facts warranted, CMS officials said.

The state inspectors, for instance, would not classify a deficiency as causing resident harm, while the federal surveyors would, according to CMS.

The tendency to underassess was evident in four deficiency cases that the Star-Advertiser analyzed from inspection reports in 2009, 2010 and this year. All four cases resulted in resident harm, but none of the institutions received sanctions.

State inspectors who evaluated the cases assigned deficiency grades that CMS officials said didn’t accurately reflect the severity of the cases. All four, they told the Star-Advertiser, warranted sanctions and should have been identified as "immediate jeopardy" situations, one of the most serious assessments an inspector can issue.

"This is just confirming that we still have some work to do," Chickering said. A CMS official currently is here conducting training.

And while Hawaii nursing homes are sanctioned at one of the lowest rates in the country, some question whether the low rate is more a reflection of a weak oversight system.

Hawaii island resident Angelo Botelho has seen firsthand how weak that oversight can be.

In December 2009, Botelho filed a complaint with the state, alleging that the nursing home where his wife was staying had demanded without notice that she be taken home the day before Thanksgiving. If Botelho didn’t take her home immediately, he said he was told, the nursing home was going to transfer her to the psychiatric ward of a nearby hospital.

Botelho brought her home.

Shortly after he filed a written complaint, the state told him the matter would be investigated.

Botelho said he has heard nothing since. No one has contacted him to say what became of the complaint.

"It’s just unbelievable," Botelho said. "It’s real frustrating."

Coming tomorrow: Authorities did not penalize one of Hawaii’s premium institutions for its failure to protect defenseless elderly residents from a sexually abusive caregiver.