L.A. County’s nursing home oversight division under scrutiny

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By Brenda Gazzar | Daily Bulletin| April 19 2021

Advocates hope that attention evoked by the coronavirus pandemic, which has resulted in more than 3,930 COVID-19 related deaths of nursing home residents and staff in the county, will help strengthen oversight of troubled nursing homes in the region.

Resident advocates have long called for reform of the Los Angeles County public health division largely in charge of regulating and overseeing local nursing homes and other long-term care facilities.

Now a recent interim report by the county’s Office of Inspector General about improving oversight and accountability in nursing homes and a final report from the county Auditor-Controller assessing the Department of Public Health’s Health Facilities Inspection Division (HFID)  have raised questions about the division’s ability to handle its job amid the coronavirus pandemic and beyond.

Both reports, commissioned by the Los Angeles County Board of Supervisors last year, were released in February, with Public Health due to formally respond to the findings of the Auditor-Controller’s report in the coming days.

Advocates hope that attention evoked by the coronavirus pandemic, which has resulted in more than 3,930 COVID-19 related deaths of nursing home residents and staff in Los Angeles County, will help strengthen HFID’s oversight of troubled nursing homes in the region.

Molly Davies, vice president of Elder Abuse Prevention and Ombudsman Services, is photographed at her WISE Healthy Aging office in Santa Monica on Tuesday, August 26, 2020.(Photo by Axel Koester, Contributing Photographer)

“(HFID is) not there to make sure facilities don’t get in trouble,” said Molly Davies, who oversees the long-term care ombudsman program in Los Angeles County that investigates and tries to resolve complaints of residents in nursing homes and other long-term care facilities.  “They are there to make sure facilities are providing good care.”

Davies cited an incident in which her ombudsman program first reported evidence of a water leak at a Glendale nursing home to Los Angeles County’s HFID in March of 2016.

Despite subsequent referrals, it wasn’t until two years later – after the matter had been referred to Cal/OSHA — that the repairs at Griffith Park Healthcare Center were made, according to a detailed timeline provided by Davies.

By March of 2018,  a surveyor from the county’s HFID had identified more than two dozen residents that could be temporarily moved out of the facility as a result of the leaks, Davies said.

It took significant advocacy and “herculean efforts” over two years to get HFID to ensure repairs to the nursing home’s leaky roof, which posed safety risks to staff, residents and anyone entering the facility, she said. The incident is one example, she said, of  her ombudsman’s office frustrating history with the division.

Griffith Park Healthcare Center in Glendale on Thursday, April 1, 2021. (Photo by Dean Musgrove, Los Angeles Daily News/SCNG)

A spokesman for Griffith Park Healthcare Center asserted that the facility “immediately acted on the information and submitted detailed plans and schematics as required by code for government and regulatory permits.” Upon receipt of the various agency approvals, he said by email, “the work was done immediately.”

Spokesman Dan Kramer said 21 residents were temporarily transferred with their consent and that of their families to another nursing home for about two months until the repairs could be made.

“Any delay was because of the regulatory process. Not the facility,” Kramer said.

The county Public Health Department did not specifically address the Glendale nursing home incident when recently asked but forwarded a recent question about it to the California Department of Public Health.

For decades, regulatory responsibility for nursing homes has been shared by the California Department of Public Health and Los Angeles County. In 2019, CDPH entered into a new agreement with the county’s public health department to fully transfer — over a period of three years — responsibility of regulating nursing homes and other health care facilities to the county.

“Every complaint and facility-reported incident is taken very seriously by the department and we conduct comprehensive investigations to ensure any substantiated violations are immediately remedied and corrected,” the state agency said in part.

(Photo by Sarah Reingewirtz, Los Angeles Daily News/SCNG)

Meanwhile, Auditor-Controller Arlene Barrera opined in her final report that HFID’s management “does not currently have the ability or capacity to adequately assume the additional responsibility” of monitoring for COVID-19 mitigation compliance should the state require the county agency to complete its other essential functions in its original contract. The contract was informally amended during the pandemic.

HFID management asserted, according to the report, that they do have the ability to meet all of the COVID-19 mitigation requirements and their amended contractual obligations with the state.

“Public Health will offer future clarifications regarding certain areas of concern related to the contract with the State, Health Facilities Inspection Division’s record keeping, and present and future workload issues,” the county agency said recently in a written statement.

The OIG report, which focused on two Pasadena nursing home evacuations that took place last year, found flaws in HFID’s crisis identification and response as well as resident abuse and neglect investigations.

The Auditor-Controller also noted that as of last June, there were more than 5,400 backlogged investigations, including 547 that were categorized as “immediate jeopardy,” that remained open. The county division is currently responsible for about 4,400 of those investigations.

HFID management “did not demonstrate that they adequately manage or track the various phases” of their current and backlogged investigations, according to the Auditor-Controller’s report. They also said the delays in completing their investigations were caused by insufficient funding in prior years, including limited staffing, which affected HFID’s ability to meet the demands of the overall workload, according to the Auditor-Controller.

(Photo by Watchara Phomicinda, The Press-Enterprise/SCNG)

The Auditor-Controller also found that HFID staff spent less time than their CDPH counterparts conducting most nursing home oversight activities. For example, HFID staff spent about 17 hours on average conducting a complaint investigation while CDPH staff spent nearly 20 hours on average.

“Several HFID staff who conduct complaint and (Facility Reported Incidents) investigations expressed feeling pressure to close investigations quickly in order to meet deadlines, reduce the number of backlogged investigations and remain current on new complaints and FRIs,” the OIG’s report noted.

Most staff reported that they are expected to submit four completed investigations per week if they are working from the office or six completed investigations per week if they are working remotely, the report noted.

Several staff — and some HFID supervisors — said they believe these expectations are “rigid, unrealistic and ultimately compromise the quality of complaint investigations,” according to the OIG report.

“Numerous staff communicated the belief that HFID leadership appears to prioritize closing investigations, at times, over the wellbeing and safety of (skilled nursing facility) residents,” the report stated.

Moreover, the majority of staff and supervisors reported feeling overworked and exhausted, which appears to have impacted staff morale, the report found.

Meanwhile, the Office of Inspector General — led by former prosecutor Max Huntsman — has recommended that the Public Health Department develop a comprehensive countywide nursing home crisis mitigation and response plan, ensure that HFID is “properly integrated” into the county public health department’s operations and that ombuds like Davies be consistently engaged as an additional layer over oversight.

The Auditor-Controller has recommended, among other things, that HFID management consider adopting the state’s completion timeframe or establishing its own for certain investigations to ensure timely completion.

The county Public Health department said it agrees with the generalized recommendations made by the offices of the inspector general and auditor-controller though it voiced “some areas of concern with characterizations or assessments made” in the reports. The OIG’s final report is slated to be released in May.

The California Department of Public Health would need to approve any changes that the county makes in response to the report, according to the state agency. That’s because the county contracts with it to provide services to the state agency on behalf of the federal Centers for Medicare and Medicaid Services

Remedying the problems outlined in the OIG’s report will “require a real investment of time and effort and maybe even resources by the county” and the leadership of the Board of Supervisors, Davies said.

“It will require an ongoing commitment because (HFID)  has been a portion of the (county public health ) department that’s been allowed to function in a dysfunctional way,” Davies said. “It will take time to course correct and will take some leadership and advocacy to do that.”

Los Angeles County Supervisor Kathryn Barger, whose district includes Glendale and Pasadena, said Monday, April 19, that the inspector general’s report highlighted “significant changes” needed at the local and state level.

“I am encouraged by the recommendations for greater oversight in Los Angeles County and fully support appointing a formal body to oversee implementation of the report – including steps by the Department of Public Health to develop a better internal structure for oversight,” Barger said in a written statement via a spokeswoman. ” At the same time, we need more assistance from the State to oversee these efforts, along with necessary resources to adequately fund staff.”

Because the county has “not taken ownership” of HFID, there should be an oversight committee — perhaps a citizen’s commission — to oversee what HFID is doing and get quarterly updates on its progress, said Tony Chicotel of California Advocates for Nursing Home Reform.

“Every few years, we get a report that things are horrible but there’s no change in the infrastructure,” Chicotel said. “I think there needs to be some group, some committee, some responsible body in charge of making sure they tow the line, that progress is being made, that (would) monitor changes and that they are recommending changes.”

Editor’s note: This article was updated on Monday, April 19, to add a comment from Los Angeles County Supervisor Kathryn Barger.