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Studies find nursing homes understaffed, inspections not standardized

Spotlight PA is an independent, nonpartisan newsroom powered by The Philadelphia Inquirer in partnership with the Pittsburgh Post-Gazette and PennLive/Patriot-News.

Part 2 of 2 in a series on nursing homes.

By Rebecca Moss

Spotlight PA

Problems in nursing homes were brought to light during this coronavirus pandemic.

The Wolf administration was repeatedly warned of dangerously low minimum staffing and weak and inconsistent inspections, all problems that could have made the outbreak worse, experts say.

Charlene Harrington, a professor emeritus of sociology and nursing at the University of California San Francisco, whose research focuses on nursing home care, called Pennsylvania’s staffing requirement “totally unsafe.”

Rachel Werner, a professor of medicine at the University of Pennsylvania, said relaxing regulations on nursing homes during the crisis “could have an impact on the care that was being delivered, but we are balancing risks here.”

“The trade-off was, had they not been relaxed, other things would be worse,” Werner said.

Fundamentally, the elder care system is poorly set up, she said, and current Medicare and Medicaid funding systems are an inadequate way to pay for the levels of nursing care needed in institutional settings.

But other experts argued that, having already failed to improve known issues with staffing, the state further abdicated its responsibilities to keep nursing home residents safe by waiving existing requirements during the pandemic.

Had the state required at least minimum staffing, Harrington and other experts said, facilities would have had more impetus to find enough employees to provide the care residents needed.

Harrington said the state “should have told the nursing homes they have to have more staff, bring in more staff, to deal with the virus.”

“Basically, they just gave the nursing home free rein to do whatever they want.”

Questions about inspections

In March, the state halted routine inspections of nursing homes, except in situations of immediate jeopardy. This was part of a federal recommendation, though the state could have chosen to supersede it.

Between mid-March and the end of May, the state conducted 851 inspections, specifically focused on how facilities dealt with infection control issues. The majority, however, were done virtually. Just 50 involved a state surveyor visiting a home in-person.

“Remote surveys allow our surveyors to do everything they would on site, except for be in the building,” Wardle, a Health Department representative, said. “They can conduct interviews, review documents, speak to anyone they need to, etc.”

But elder care advocates and ombudsmen say remote inspections are a dangerous practice that leaves facilities ample space to assure regulators there are no problems over the phone, and avoid citations and fines.

According to inspections made public since the virus took root in the state, regulators have rarely reported any problems. At least 33 inspections were triggered specifically in response to complaints about the coronavirus, but the state said it found no problems at these homes, more than 60% of which have seen resident deaths.

In Lehigh County, the state found no problems at CedarBrook Senior Care and Rehabilitation, where 37 people have died, nor at Lehigh Center, where there have been 24 deaths.

No problems detected

“Higher quality and lower quality facilities can have cases and death,” David Stevenson, a health-policy professor at Vanderbilt University School of Medicine, said. Still, Stevenson said he believes “that higher quality practices and higher staffing matter … to residents’ outcomes even in a pandemic.”

When staff or family members report problems at a facility, but the state finds nothing, that should raise questions, he said. These complaints, now more than ever, are “very much something for the state to be on top of.”

Inspections conducted during the past two months in response to noncoronavirus complaints have also rarely involved citations.

A separate federal investigation in early May resulted in a roughly $62,500 fine after inspectors found issues including unclean medical equipment and problems with medical record-keeping at the facility.

“It definitely is concerning, to say the least,” said David Grabowski, a professor of health care policy at Harvard Medical School.

Problems with how Pennsylvania conducts its inspections of homes, and whether the results of those inspections are consistent and accurate, were among the ongoing problems the state has promised to address since they were identified in the 2016 audit.

The auditor general’s office found “a lack of consistency in surveys and quality standards” and said the state had no policy to check whether a facility was in compliance with staffing requirements. (This has since been improved at the federal level by requiring homes to submit payroll data.)

No standardized procedures

According to the 2016 audit, nursing home surveyors often found serious problems, but sometimes chose not to issue citations against the facility, and then did not document why enforcement action had not been taken. There was no standardized procedure among regional offices, leading to inconsistent assessments of the severity of problems and when facilities should be cited.

The consequence of this was in part made evident by a 2016 PennLive investigation that found seven of 46 deaths directly related to poor care at nursing homes were only classified as “minimal harm” violations. This is a minor citation, usually tied to a resident experiencing some discomfort, not death. Only one of these deaths had been classified as “immediate jeopardy,” which is the standard for problems resulting in death or significant harm.

Three years later, the auditor general found that while some policies had been updated, the survey process remained inconsistent and there was an evident need to better train nursing home inspectors. Auditor General Eugene DePasquale said a third-party trainer might be warranted.

But even before the first audit, the Department of Health saw the need for better oversight.

The agency hired a training manager in 2014 to oversee the state’s surveyors and standardize and improve the quality of statewide inspections, according to an internal job description. But the following year, the role was all but hamstrung, according to a complaint submitted to the auditor general’s office in 2018 and reviewed by Spotlight PA.

The complaint said all nursing home inspection training was halted in the fall of 2017. The issue was brought directly to Dr. Rachel Levine, the health secretary, according to the document.

DePasquale told Spotlight PA his office reviewed the complaint, and its allegations contributed to findings in the 2019 audit.

“It is something we stand behind - that consistency (in inspections) needs to be improved,” DePasquale said. “Broadly speaking, the issues that we addressed, we still believe need to be resolved.”

A Department of Health employee, who asked not to be named for fear of retaliation, said the lack of progress in training inspectors and other problems within the department can make it hard for the public to rely on surveys as a measure of whether nursing homes are providing adequate care. The employee said it was common for violations to be erased from inspection reports and for some inspectors to be too cozy with nursing home administrators.

The audit also found there were concerns among advocates about the close relationship between some inspectors and nursing home administrators, raising the possibility some complaints were not thoroughly investigated or problems penalized. That would be more of a concern during the coronavirus, when lenient enforcement could have allowed the virus to spread faster, putting more lives at risk.

The state did not directly address this in its response to the auditor general but said it follows federal guidelines to handle complaints and uses online and in-person training to improve.

Nationwide, studies have found little relationship between the quality of a home and whether the virus has infected residents there. Instead, facilities located in a region with a high rate of cases are more likely to see infections.

Still, if the survey used to assess the quality of a home is inaccurate or has not rigorously investigated or enforced the quality of care, it is harder to use the results as a true measure of a facility, experts said.

What we do know, he said, is that “COVID has been absolutely magnified in the U.S. by the more systemic problems - it could be an opportunity to rethink how we regulate.”

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As of early June, more than 4,200 residents of Pennsylvania's long-term-care facilities have died from the coronavirus, nearly 70% of all the deaths attributed to the disease in the state.