The state has failed to inspect more than a third of Hawaii’s 45 nursing homes within the time frame required by federal law, reflecting an oversight gap that some experts say could come at the expense of the facilities’ vulnerable residents.

Concerned about the problem, the federal government is threatening to fine the state as much as $121,000 if the timeliness requirements are not met by the end of September.

"The public should hold the state accountable to make sure it’s meeting its obligations," said Steven Chickering, associate regional administrator for the Centers for Medicare and Medicaid Services, which oversees nursing homes nationally and contracts with the state Department of Health to inspect those in Hawaii.

A Health Department official said his agency is well on its way to meeting the inspection requirements.

The timeliness problem is especially acute on the neighbor islands, where the last "annual" inspections at the 17 facilities were conducted an average of 20 months ago, according to a Honolulu Star-Advertiser analysis of federal data. U.S. law requires the inspections to be spaced no more than 15 months apart.

A dozen of the nursing homes on Maui, Kauai and Hawaii island have not had the standard inspections, called surveys, for at least 22 months and two of those have gone nearly three years without one, according to the data.

"This is a serious problem," said Robyn Grant, director of public policy and advocacy for the Washington, D.C.-based National Consumer Voice for Quality Long-Term Care. "To go beyond (the required time frame) opens up the whole problem of what is happening within these facilities."

For the inspections, regulators typically spend several days poring through records and interviewing staff and residents to ensure the facility is meeting minimum health and safety regulations. The inspections are unannounced.

"The public should be concerned about nursing homes not inspected each year — as the law requires — because quality of care can change quickly without the oversight of regulators and the advocacy of ombudsmen," wrote Patty Ducayet, president of the National Association of State Long-Term Care Ombudsman Programs, in an email to the Star-Advertiser.

The Health Department blames the timeliness problem on a lack of resources.

"Implementing a consistent inspection schedule requires resources and qualified individuals," wrote Keith Ridley, chief of the department’s Office of Health Care Assurance, in a statement to the newspaper. "Unfortunately, when budgets are constrained, this has a direct impact on our ability to perform at an optimal level, and we must do what we can to adjust to budget cuts."

Ridley, however, said his office has performed inspections on 12 of 15 neighbor island facilities identified as priorities by CMS — Chickering’s agency — and the state. The remaining three inspections are scheduled to be completed in July, ahead of schedule, he added.

Ridley acknowledged that neighbor island inspections were put on hold in the previous fiscal year because of budget constraints, resulting in checks being done an average of every 20 months instead of 15.

On Oahu, the average between inspections is 10 months — half the neighbor island total.

That discrepancy means neighbor islanders are bearing a disproportionate burden of the budget squeeze, raising questions of fairness.

"Long delays, mostly on the neighbor islands, create a real risk that we will have a two-tiered health care system, one for Oahu and another for the neighbor islands," said Sen. Josh Green, a Hawaii island resident and chairman of the Senate Health Committee. "This isn’t fair to the people on the Big Island, Maui, Kauai, Lanai and Molokai, who already have health care access issues as a result of physician shortages."

Green, a physician, said he works in hospitals with nursing homes and knows "these checks are necessary and productive for maintenance of patient safety and quality of care."

The state’s failure to do the inspections within 15 months does not necessarily mean that the quality of care is slipping at those facilities. But with major gaps in oversight, the facilities can get lax in trying to maintain the highest levels of care, experts say.

"If there aren’t surveys, there’s not that outside pressure," said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy in Washington, D.C. She called Hawaii’s timeliness problem "very serious."

What’s especially worrisome, experts say, is when poorly rated facilities go long stretches without inspections.

In Hawaii, two of the five nursing homes that have gone the longest without standard inspections — Hale Ho’ola Hamakua on Hawaii island and Hale Makua in Wailuku — are rated two stars in a five-star system by Nursing Home Compare, a federal government website that provides consumers with quality-of-care information.

The government system assigns five stars to the highest-rated facilities and one star to the lowest-rated. In Hawaii, none has one star, but several are designated two-star facilities, including Hale Ho’ola, which has the distinction of going the longest — 34 months — without a standard inspection, according to Nursing Home Compare data.

In January, Hale Ho’ola had an inspection triggered by a specific complaint, but that is more focused and not as extensive as the standard ones. Complaint-based inspections are not substitutes for standard ones, according to CMS.

Chickering, the federal official, said his agency has been aware of Hawaii’s difficulties in meeting the timeliness requirements.

"We are concerned," he said.

Last fiscal year, Chickering added, the state did not inspect 11 nursing homes within the 15.9 months his agency uses as the required threshold.

Because of that, his agency withheld $121,000 in federal funds from the state — money Hawaii stands to lose if the federal requirements are not meet by the end of September, according to Chickering.

For each facility in which the state fails to meet the requirements, CMS will fine the state $11,000, with $121,000 being the maximum potential sanction, he added.

In addition to budget problems, Hawaii has had difficulty meeting the timeliness requirements because, like other states, it has struggled in making the transition from a paper-based to a computer-based system for documenting inspection data, according to Chickering. But the indications CMS has thus far are that Hawaii is on pace to meet the inspection requirements by the end of September, he said.

Regular surveys and feedback from families are the two primary ways the state monitors quality of care in nursing homes, according to Ridley.

"We recognize that our current situation regarding inspections is not ideal," he wrote. "However, in addition to inspections, we also have a system of investigating specific concerns raised by family members. These often lead to identifying broader, systemic issues that we work to improve with the nursing facility."

John McDermott, the state’s long-term-care ombudsman, said Hawaii is fortunate that most nursing homes here provide excellent care. But without regular monitoring, "things can deteriorate quickly," he added.

McDermott noted the major disparity between the neighbor island and Oahu inspection time lags.

"Bottom line: Our neighbor island kupuna are entitled to the same protection as their peers on Oahu," he said. "The powers that be must provide the financial resources necessary so the Department of Health can do its job."

ENLARGE CHART