The state failed to meet nearly 70 percent of federal performance standards related to inspections of nursing homes and other federally certified health care facilities last year, according to a new evaluation by the Centers for Medicare and Medicaid Services.

The state Department of Health, which does the inspections, called surveys, largely attributed the deficiencies to a lack of staffing.

And it said the recent hiring of two inspectors and an administrative support staffer will help the department address areas in which it still is deficient. Health Department officials are also seeking authorization from the Legislature to hire two additional inspectors in each of the next two budget years.

Federal officials said they were encouraged by the initial steps the department has taken to resolve the problems.

But if the state can’t demonstrate significant progress in the months ahead, it could take a sizable financial hit.

If Hawaii doesn’t meet certain performance benchmarks established by the centers by the end of September, it stands to lose as much as $313,500 in federal funds that already have been allocated for the department but have yet to be turned over, according to federal officials.

The recent evaluation, obtained by the Hono­lulu Star-Advertiser through a government rec­ords request, covered the federal fiscal year that ended Sept. 30, and showed that Hawaii fell short in nine of 13 performance categories, or 69 percent.

The categories in which the department’s Office of Health Care Assurance, referred to as the state survey agency, failed to meet standards range from frequency of nursing home inspections to the quality of complaint investigations.

National experts expressed alarm at Hawaii’s evaluation.

"The Hawaii survey agency’s failure to meet important standards for survey performance puts nursing home residents in serious jeopardy," said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy in Washington, D.C.

In an email to the Star-Advertiser, Edelman noted that the purpose of the inspection process is to ensure that residents enjoy the high quality of care and high quality of life guaranteed by federal law.

"Surveys are the state’s chief method for identifying nursing facilities’ failures in care and for imposing appropriate remedies," she wrote. "The state’s failure to conduct surveys effectively jeopardizes residents’ health, safety, welfare and rights and allows facilities to continue receiving full public reimbursement despite providing poor care." She was referring to reimbursements for government-funded care.

Charlene Harrington, professor emeritus in social and behavioral sciences at the University of Cali­for­nia’s School of Nursing in San Francisco, raised similar concerns.

"This seems like a very serious situation and suggests that the agency may be underfunded and lacking an adequate number of surveyors," Harrington said in an email. "All of these failures can reduce the effectiveness of the nursing home enforcement system."

Harrington has co-authored a study showing that states with stronger enforcement have better nursing home quality.

Yet the state’s poor performance in the inspection arena contrasts with other recent measures portraying a more upbeat picture regarding quality of care.

In February the centers issued nursing home ratings under a newly revised system, and Hawaii had the highest percentage of top-ranked facilities in the country. It also had the lowest percentage of the lowest-ranked homes of any state and led the nation in several other quality measures.

One of the more serious problems the DOH has had in its oversight of nursing homes has been timeliness of inspections. Though referred to as annual reviews, the inspections must be done no more than 15.9 months apart under federal law.

But the statewide average last fiscal year was 19.1 months, according to the department’s draft response to the federal evaluation. Only 29 of the state’s 46 nursing homes were surveyed during that period.

The problem has been particularly acute on the neighbor islands, where inspections for some facilities weren’t done until nearly two to three years after the previous ones. Inspectors are based on Oahu.

Steven Chickering, the centers’ associate regional administrator, based in San Francisco, told the Star-Advertiser that Hawaii is not unique in facing challenges in trying to meet the various mandates for inspecting health care facilities on behalf of the federal government.

The centers pay state agencies to inspect such facilities for compliance with federal regulations.

Chickering said his agency recognizes that understaffing and lack of resources have been a problem for Hawaii, and, because of that the centers increased the state’s allocation of federal funds this fiscal year by more than 30 percent — the biggest jump among all the states.

Still, there is concern about the recent evaluation results, Chickering added. "We take this very seriously, obviously."

The $313,500 that his agency has linked to the meeting of benchmarks is part of nearly $1.3 million that has been allocated by the centers to the Office of Health Care Assurance for the current fiscal year.

The state recently submitted a draft plan for addressing the inspection-related deficiencies, including the requests for additional inspectors. But Chickering couldn’t say whether his agency was satisfied with the response because the plan still is under review.

He did say, though, that officials were encouraged by indications of recent progress, including the hiring of more inspectors.

Keith Ridley, who heads the Office of Health Care Assurance, said his agency’s goal is to complete inspections of all skilled-nursing facilities in Hawaii by the end of September.

"We have a very full and tight schedule," he added, saying he was confident the goal could be met but indicating that there’s almost no room for unexpected developments or disruptions.

Edelman, policy attorney at the Center for Medicare Advocacy, said the state’s failure to meet the standard for conducting quality investigations of nursing home complaints is worrisome.

"Complaint investigations are often the basis for many of the most serious deficiencies cited by survey agencies nationwide," she wrote. "Complaint investigations are especially critical because they occur at totally unpredictable times and because complainants often identify and carefully document egregious failures in care, including failures that have not been identified in the annual survey."

Ridley said the number and severity of deficiencies that Hawaii’s inspectors document through the annual surveys fall within the average ranges for other facilities within the Western region and nationally. That runs counter to the notion that Hawaii inspectors are too lenient, he said.