By Chris Comisac
Bureau Chief
Capitolwire
HARRISBURG (July 26) – A state Health Department request that an audit be done regarding the agency’s efforts to regulate and oversee Pennsylvania’s nursing homes has produced a roadmap to improve those efforts.
Auditor General Eugene DePasquale and Department of Health Secretary Karen Murphy Tuesday morning held a joint press conference in the state Capitol to announce the release of a Nursing Home Audit report and its recommendations.
The 13 findings and 23 recommendations contained within the 91-page audit seek to address three areas of concern: Inadequate review of nurse staffing levels; DOH handling of complaints; and sanctions imposed on poor-performing facilities.
Regarding the audit’s results, DePasquale cautioned, “These findings should not necessarily be construed that every nursing home is good or bad or something in between – this was not an audit of nursing homes; this was an audit of the Department of Health’s oversight of the industry.”
In Pennsylvania, nursing home residents are required to receive a minimum of 2.7 hours of direct nursing care – skilled nursing care, not personal care – each day, although prior to the audit, the DOH had no policies to ensure nursing homes met that requirement.
When auditors reviewed annual surveys from 42 nursing homes, they found 71 percent of the DOH staffing reviews were incomplete, either with regard to the period of time reviewed by the DOH or the review’s supporting documentation, said DePasquale.
“What this tells me is the department was not looking,” he said. “And when you don’t look, there’s no way you discover problems, or that a facility is doing okay.”
Additionally, the audit found the reviews used inconsistent methods, so facilities were not all held to the same standard, and when compliance issues were found regarding the 2.7-hour minimum care level, the DOH did little to enforce the requirement.
“Out of the 7,235 instances in which DOH completed a nursing home survey, it issued just 13 citations — that’s only 0.2 percent of the time,” DePasquale said. “To me that’s statistically – I won’t say insignificant – but almost impossible, if you’re doing the proper reviews all the time.”
“It seems clear that prior to this audit, the DOH was not getting to the root of the problem – some facilities simply lacked sufficient nursing staff,” said DePasquale. “And it’s simple, if nursing homes aren’t sufficiently staffed, the quality of life and the quality of care for resident will suffer.”
The audit also notes the 2.7-hour care minimum was implemented in 1999 and the federal Centers for Medicare and Medicaid Services (CMS) has since then sponsored research that suggested, but not mandated, 4.1 hours of direct care per day per resident is a more appropriate minimum level of care.
The DOH has created a Nursing Home Task Force, including national and state experts, with the goal of offering recommendations to improve the quality and safety of the care delivered in nursing homes, said Murphy. She added the department has been in discussions with long-term care providers regarding the review of current long-term care regulations and potential changes to those rules.
With regard to complaint handling, the audit found the department for three years, starting in 2012, failed to accept anonymous complaints in violation of a CMS requirement that the department must ensure the “privacy and anonymity” of every person making a complaint.
Once it did start taking those complaints in 2015, the number of complaints increase by 63 percent but the DOH didn’t have enough staff to complete an investigation in a timely fashion.
“Instead of completing an investigation in two weeks, it could drag out for nearly a month,” DePasquale said. “The longer an investigation takes to complete, the longer a problem might go uncorrected — and the more likely it is that residents could be harmed.”
DePasquale said the audit also found the DOH could have done a better job at sanctioning facilities, and explaining the lack of sanctions in certain circumstances, when deficiencies within their care operations were identified.
“DOH has considerable administrative discretion when pursuing sanctions, and we agree that not every instance of noncompliance may warrant a fine,” DePasquale said. “However, when a facility is not sanctioned but could have been, there needs to be an explanation.”
During the 22-month audit period, DOH cited 9,189 federal deficiencies in nursing homes and the federal government issued more than $2 million in fines to Pennsylvania nursing homes, but the DOH issued only 47 state sanctions, 32 of which were fines totaling $172,350.
The department told auditors they prefer to mandate training to address deficiencies, particularly in cases where a facility is also facing federal sanctions, but those same auditors found only 30 in-service trainings were ordered during the audit period, and inconsistent documentation regarding sanction-related decision-making.
Murphy said the department has since increased enforcement of regulatory sanctions.
The Health Secretary thanked DePasquale for the audit, indicating it will help the department “better serve the nursing home residents of the commonwealth.”
“Last July, I asked Auditor General DePasquale to perform an independent review and audit the policies and procedures already in place in the Department of Health and recommend ways the department could improve how it enforces statutory enforcement authority,” said Murphy of the start of the process.
“They wanted to get it right,” said DePasquale. “Not only we’re there things they were going to do, but they wanted an independent analysis and review of what those issues would be, without them having any say in what the outcome would be.”
“This audit is an example of how the process should work,” DePasquale said. “DOH began hearing concerns about its oversight of nursing homes and asked us to conduct an audit.”
“Every request for information was met and instantaneously delivered,” said DePasquale of the audit process with the DOH. “We believe that they were and will be considered a model of cooperation for the future.”
“As our team began finding deficient practices, DOH immediately responded by implementing changes,” DePasquale explained.
“We have already launched a multi-faceted, performance improvement initiative that addresses many of the audit recommendations and are committed to continuing to accelerate the department’s efforts to make a positive impact on improving the lives of the more than 80,000 Pennsylvanians who rely on nursing homes to meet their long-term health care needs,” Murphy said.
Despite some of the critical findings contained within the audit, DePasquale said “we 100 percent believe that the employees of the department are dedicated public servants that are trying to get it right.”
The reaction to the audit, from both the nursing home industry and the union representing a significant portion of nursing home workers, was positive.
“We applaud the Pennsylvania Department of Health for engaging the Auditor General in conducting a performance review audit of the policies and procedures already in place in the Department of Health including recommendations on ways the department can improve how it enforces its statutory authority,” said W. Russell McDaid, president and CEO of the Pennsylvania Health Care Association. “We concur with the report that ensuring that nursing home residents’ quality of care and quality of life is protected is our shared top priority.”
“Pennsylvania’s skilled nursing providers employ more than 120,000 hardworking women and men who daily provide the highest level of care to safeguard our sickest, frailest elderly and disabled residents so they may live a healthy, safe life and age with dignity and respect, McDaid said. “These dedicated employees work hard to ensure that they are in full compliance with the strict state and federal regulations that govern the care they provide to the approximately 80,000 residents receiving care each and every day. And we welcome the opportunity to work with the department and the surveyors to continue to provide that high level of care.”
“The Pennsylvania seniors living in nursing homes deserve and require high quality care,” said SEIU Healthcare PA President Matt Yarnell, whose union represents 10,000 nursing home workers. “It’s the Department of Health’s job to provide the necessary oversight to ensure that all providers are meeting the highest standards of care. Both Auditor General Eugene DePasquale and Secretary of Health Karen Murphy should be recognized for their leadership in addressing issues that impact the quality of long term care provided to thousands of PA seniors and people living with disabilities.”
“Our experience is most providers want to provide the highest quality care and many of our industry partners have expressed interest in improving the standards that all providers should be meeting – particularly raising the minimum staffing requirements,” Yarnell said. “We need to make sure there are enough caregivers to provide the highest quality care and that these jobs are living wage jobs with good benefits so we can recruit and retain the best staff. If we can do that, we can go a long way to address many of the challenges raised by today’s audit.”
