An audit of the Department of Health office that oversees nursing homes, hospitals and other health care facilities shows what legislators called an “outrageous” disregard for state laws requiring routine inspections and prompt investigation of complaints.
But while health officials have bristled at the probes and criticism to which they’ve been subjected since the closure of Hillside Health Center last fall, acting Health Director David R. Gifford, who just took over the department, said the audit is on target and will lead to changes.
“I think overall, it’s accurate,” said Gifford, who did not attend Auditor General Ernest A. Almonte’s presentation to a legislative committee, but said he’d read the full report.
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“I’m sure one could quibble with little things here or there,” Gifford said, “but I think the general intent and message in the different categories indicate areas that we need to address.”
Identifying the problems, he noted, is the first step in quality improvement, his specialty.
And as Almonte told the Permanent Joint Legislative Committee on Health Care Oversight – the five of 12 members who came – there are many serious problems with the way the Office of Facilities Regulation does its work.
Due to a “lack of resources,” but also other issues, the regulation office in the last two and a half years has overwhelmingly ignored state inspection and complaint-response requirements, Almonte said, and while it’s “largely” complied with less-stringent federal mandates, even there it’s fallen short.
Of 811 complaints received in fiscal 2004, for example, only 80 were investigated in the time required by state law, Almonte said – within 24 hours if there’s “immediate jeopardy” to a patient, or within seven days otherwise. One of only two “immediate jeopardy” cases didn’t get a response within two working days, as required by the federal government.
Health officials told Almonte they used a “risk-based approach,” focusing their limited resources on the most serious cases. But the auditor general called the office’s triage system into question, noting that of 783 cases designated as low-priority in fiscal 2004, meaning the complaints were left to be investigated during the next scheduled inspection, a federal review later found 40 percent required a higher classification.
“This is pretty troubling to me,” said Rep. Al Gemma (D-Warwick). “Why is this: Not enough people? They didn’t give a damn? This is awful.”
State Rep. Joseph N. McNamara (D-Warwick) noted that the Office of Facilities Regulation seemed to have been “ignoring the law 90 percent of the time,” adding that even if health officials didn’t have the resources to comply with the law, “it’s outrageous that they would choose to do this and not notify anyone.”
State Rep. Steven M. Costantino (D-Providence), who chaired the meeting, had a bigger concern that Almonte could not assuage: Even if the facilities regulation office does respond to a complaint, and it finds problems, and the facility pledges to correct them, how does anyone know the problem was really fixed? Audit manager Tim McCormick said as far as he could tell, inspectors would check at the next scheduled inspection, within nine to 15 months.
“I think that’s absolutely outrageous,” Costantino said, noting how much harm could come to a nursing home’s residents in that time.
Asked about complaint response and follow-up, Gifford said the Department of Health has hired a consultant to “review our complaint process and figure out ways to do it more effectively and efficiently,” including how cases are now prioritized. As for follow-up, Gifford said he’s hoping to make big changes there, though not necessarily by assigning inspectors to visit troubled nursing homes repeatedly.
Instead, he said, the department may require homes to pay for external “quality monitors” to supervise their progress – perhaps in lieu of paying a fine for violations.
“That’s probably a better use of resources,” he said. “If our only strategy is to punish the provider, that’s likely to make it worse for the patient.”
Gifford is also a big believer in prevention and outreach; in his previous life, as chief medical officer at Rhode Island Quality Partners and a professor at Brown Medical School, Gifford worked directly with nursing homes to help them improve care and correct problems from within. He said he’s hoping to apply some of those concepts in his new job now.
“Right now we inspect but wait until things get quite bad to do anything,” he said. “I think we need to figure out a way to address things sooner, so we don’t have to dig ourselves out of such a deep hole. We need a preventive strategy – that’s one of the tenets of public health.”
As things stand now, however, the Office of Facilities Regulation isn’t keeping up with regular inspections. Of 102 nursing homes under its purview, nine didn’t get their annual inspection last year, and 93 didn’t get the two surprise visits they’re supposed to get in between the annual reviews, Almonte reported.
(Rhode Island’s 15 hospitals have gotten even less attention: 14 got their licenses renewed without an inspection, and Almonte said health officials had told him they relied on the Joint Commission on Accreditation of Healthcare Organizations’ triennial accreditation reviews as a substitute for regular inspections.)
Part of the solution to that problem, Gifford said, is to add more inspectors. Right now the office has 25, according to Almonte, and they have to inspect not only the nursing homes and hospitals, but more than 500 other facilities: clinical labs, school health centers, even 53 tattoo parlors.
Gov. Donald L. Carcieri has requested six more inspectors in his fiscal 2006 budget, Gifford said, and while legislators haven’t all signed on yet, “I have not heard anyone not say that we need more resources.”
But the burden is also “on us,” Gifford added, to become more efficient.
