The state last year failed to meet more than half of the federal performance standards for inspections of nursing homes and other health care facilities, continuing a history of poor marks that patient advocates say could signal worsening care.

Even if care has been unaffected, the state Department of Health’s lackluster performance has cost the agency nearly $350,000 in reduced federal grants over the past three years.

But a department official, while acknowledging the need for his agency to do better, noted that it has improved in key areas, such as reducing the maximum months and average interval between nursing-home inspections. The numbers he cited reflected the best marks the department has recorded over the past six years, according to DOH data.

“We know there’s still a long list of other things we need to do,” said Keith Ridley, who heads the department’s Office of Health Care Assurance, which handles inspections.

In the most recent evaluation by the Centers for Medicare & Medicaid Services, the federal agency found that DOH failed to meet eight of 13 minimum inspection standards linked to frequency, quality and enforcement — or a 61 percent failure rate. That was the same rate as the prior year and only slightly improved from the one before that, when the agency did not meet standards in nine of 13 categories, or 69 percent, for the year that ended Sept. 30, 2014.

In each of the past three years, the state failed to meet the federal threshold for doing inspections on a timely basis and for prioritizing complaints and incidents at the facilities. How quickly a complaint is investigated depends on the priority it is assigned.

The state also fell short in documenting deficiencies found during inspections after having met that standard in the prior two years.

CMS hires health agencies around the country to perform inspections of nursing homes, ambulatory surgical centers, home health agencies, dialysis units, rural hospitals and other federally certified providers that receive Medicare and Medicaid dollars. Inspectors check to ensure the facilities are complying with regulations related to care and safety.

CMS, in turn, monitors the agencies to ensure the inspections, called surveys, are done properly.

Steven Chickering, CMS associate regional administrator for its western division of survey and certification in San Francisco, told the Honolulu Star-Advertiser in a phone interview that he was concerned about Hawaii’s inspection deficiencies but was satisfied with the steps taken thus far to address them.

“I think there’s opportunities to take additional steps,” he said.

Substandard care

National experts said the state’s history of poor marks is disconcerting and may be putting patients at risk.

“The state isn’t doing the level of oversight it needs to do,” Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, said in a phone interview from Washington, D.C. “That means it’s not protecting residents.”

Not doing inspections on a timely basis is particularly troubling, according to Robyn Grant, director of public policy advocacy for the National Consumer Voice for Quality Long-Term Care in Washington.

“When inspections are not conducted as frequently as required, residents/patients may experience substandard care and/or harm for a prolonged period of time,” Grant wrote in an email. “Inspections that are done on a timely basis mean that problems can be identified earlier and therefore corrected sooner.”

Similar concerns apply to prioritizing complaints and incidents, she added.

“If complaints are not properly prioritized, an investigation into a serious problem may be delayed,” Grant wrote. “During that time the problem may continue and possibly even worsen.”

Ridley said advocates are right to be concerned when inspections are not done when they should be. “We agree with that,” he said. “We take that seriously.”

Ridley noted that his agency is down three of 10 inspectors following the retirement this year of two and the relocation of a third. But Ridley was optimistic those positions would be filled within the next several months.

He also cited progress being made in some areas.

In the 2015 CMS evaluation, for instance, the state got dinged for not inspecting 31 nursing homes within the 15.9 months required by the federal government. In the 2016 evaluation, that number was down to two. But that still meant the state didn’t meet the overall standard involving frequency of nursing home inspections.

And while Ridley acknowledged that quality of care could be affected if inspections are not performed on a timely basis, he said Hawaii is fortunate, especially compared with the mainland, to have a strong culture of providing good care.

He cited as evidence two key statistics: Hawaii continues to be among the five states with the highest percentage of nursing homes rated five stars, the top rating, and is the only state to have less than 10 percent of its long-term nursing home residents on anti-psychotic medications, according to federal data.

Having a low percentage of residents — excluding those with schizophrenia, Huntington’s disease or Tourette’s syndrome – on antipsychotics is viewed as a positive quality measure. Hawaii’s most recent level was 7.5 percent, the data show.

Federal funds cut

The problem of ensuring timely inspections of Hawaii nursing homes became bad enough in recent years that CMS threatened to withhold varying amounts of federal funds if the state didn’t meet certain benchmarks.

In 2014, for example, the state didn’t even survey 17 of the 46 nursing homes here, and the average interval between inspections was 19.1 months, well above the maximum of 12.9 set by the federal government.

But Hawaii was able to meet the benchmarks the past few years and didn’t suffer any financial penalties tied to those benchmarks, according to Chickering.

In 2016, Hawaii was able to reduce the average interval between nursing home inspections to 11.3 months, the lowest level of the past six years, according to DOH data. The maximum time between inspections was cut to 17.8 months, also a six-year low.

The department did, however, have its federal grants reduced by $346,000 over the past three years because of missed work, according to Ridley.

Chickering said it would be difficult to compare Hawaii’s performance marks with other states because each state faces different circumstances that can affect inspection efforts.

He also could not say whether Hawaii’s survey deficiencies have affected quality of care. That would have to be closely studied before an assessment could be made, according to Chickering.

Ridley said the federal government realizes his agency needs more resources to enhance its inspection efforts, and DOH, the governor and key legislators have been supportive. But Ridley realizes there are many programs competing for limited funding.

“We’re going to continue fighting for resources we need,” Ridley said.