U-R update

INDIANAPOLIS – A federal report analyzing the dearth of thorough oversight at nursing homes nationwide during the COVID-19 pandemic found the list of facilities that have operated for more than a year without a recertification inspection continues to grow.

The U.S. Department of Health and Human Services Office of Inspector General released a report in late July detailing how states failed to address inspection backlogs -- vigorous in-person oversight visits commonly called “surveys” by regulators. The federal overseer found 71% of nursing homes nationwide lingered more than 16 months without an annual survey.

In April, a CNHI reporting project found found 51% of the nation’s nursing homes had gone without inspections for at least 18 months -- a wider timeframe than the July report that accounted for state delays, which predate the pandemic. Since that time, the list of facilities overdue for inspections has grown.

“Comprehensive nursing home inspections – standard surveys – are CMS’s main tool to ensure that nursing homes meet the minimum standards necessary for the safety and wellbeing of residents,” the report said. “Yet, due to the COVID-19 pandemic, States have conducted substantially fewer of these standard surveys, which help to identify and address deficiencies.”

During a typical year, the Centers for Medicare and Medicaid Services (CMS) requires states conduct surveys at least every 15 months to meet federal requirements and maintain Medicare/ Medicaid certifications. The intense, multi-day surveys often uncover an assortment of deficiencies in care and require more of operators than other oversight.

In March 2020, CMS suspended recertification surveys and pivoted to infection control surveys, designed to prepare nursing homes for the onslaught of COVID-19 cases. Nursing homes care for some of the most medically vulnerable people in communal spaces, making such facilities the most prone to infectious diseases like COVID-19.

As detailed in CNHI’s report, these surveys catch more problems than the infection control surveys, which can last as little as a half hour. In the report, Newfane Rehab & Health Care Center in Western New York hadn’t had a recertification survey since September 2019. Inspectors visited the facility for a recertification survey in late June, 21 months after the last one.

Inspectors found moderately serious deficiencies during both inspections - hazardous cord placement in the 2019 survey was fixed but the facility had another electrical problem in 2021, when inspectors discovered exposed wiring.

Infection control surveys between recertification inspections don’t prioritize these issues, focusing instead on delays reporting COVID-19 information.

Newfane, a COVID-19 hotspot in May 2020, has reported 31 confirmed COVID-19 deaths and seven presumed COVID-19 deaths at the 165-bed facility, according to New York State’s Aug. 21 release.

Newfane didn’t respond to requests for comment.

Even with the change from detail-oriented recertification surveys to infection control surveys, an estimated 133,736 nursing home residents have died from COVID-19, accounting for more than 20% of all COVID-19 deaths.

CMS had good reasons for delaying inspections, Tamara Konetzka, a public health professor at the University of Chicago said, noting the need to focus on COVID-19’s spread and concerns about inspectors introducing the virus to the facility or catching the virus from residents.

“At the same time, it is worrisome not to have inspections, especially when visitation has been curtailed,” said Konetzka, who studies the American long-term care system. “We know that family members help monitor and ensure appropriate care… so inspections and families work in complementary ways.”

The loss of both visitation and inspections amounted to “almost no monitoring at all,” Konetzka said.

CMS authorized states to resume the thorough inspections in August 2020, so long as they had the resources necessary to do so. As the report demonstrates, few states managed to catch up on inspection backlogs.

As of June 2020, 8% of nursing homes had gone at least 16 months without a standard survey. Within a year, that backlog ballooned to 71% of nursing homes nationwide, according to the OIG report.

The report’s authors recommend that CMS give states guidance for prioritizing survey backlogs as well as timeframes to complete those inspections – which CMS told CNHI it was doing in March. However, as the report outlines, the problem grew worse since CNHI’s reporting this spring.

“We encourage CMS to take the steps described above to implement this recommendation and help States provide needed oversight of nursing homes,” the report concluded.

Because of the staffing shortages and uncertainty, Konetzka argued that maintaining visitation should be prioritized because it can be safely executed and allow for some oversight. Resuming inspections should be based on previous nursing home performance, as rated by CMS’ Nursing Home Compare, and not COVID outcomes.

“Those are the facilities where we know that quality problems are likely ongoing and where the lack of monitoring is likely to be most dangerous,” Konetzka said.

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