Nursing home staffing needs scrutiny
The Pennsylvania Health Department does too little to ensure that the state’s 700 nursing homes are meeting minimum staffing standards in caring for vulnerable residents, according to an audit released Tuesday.
The report by Auditor General Eugene DePasquale also said the state is overdue for legislative review of whether staffing requirements and maximum fines against nursing homes should be raised, considering they have been unchanged in the 21st century.
How state inspectors enforce — or don’t enforce, in this case — the staffing standards was the primary focus of a review in which Mr. DePasquale praised Health Secretary Karen Murphy for inviting the audit a year ago and for already initiating many changes in line with its findings.
In one of the audit’s sharpest criticisms, it noted the Health Department for three years had refused to accept anonymous complaints from the public about nursing home conditions. Ms. Murphy last summer resumed investigating confidential tips, a practice stopped by the Corbett administration, and it helped lead to a 34 percent increase in complaints received in 2015.
The auditor general called “absolutely breathtaking” the three-year prohibition on confidential complaints, as following up on public reports is an essential supplement to the annual inspections mandated of every facility. Mr. DePasquale said he believed the policy was imposed “with the intent to silence critics.”
In its focus on staffing levels, the audit explained it is one measure that would likely be closely correlated to the care delivered to 80,000 patients across the state. Pennsylvania since 1999 has required minimum staffing that equates to at least 2.7 hours of care, per patient per
day, from aides or nurses. The audit noted that although the federal government sets no minimum, government-sponsored research suggested 4.1 hours of care would be needed for proper quality assurance.
But the state has been lax even in enforcing the 2.7hour standard, the audit said, citing numerous inconsistencies and lack of documentation in verifying the facilities’ reported staffing levels. The Health Department responded that it recognized those problems and took steps in April to make procedures used by inspectors more effective.
The audit noted the state rarely cited facilities for inadequate staffing — just 13 times over a 22-month period — even when it found other quality problems that could have resulted from the shortages, and it never makes use of an enforcement tool to order that staffing be increased.
“It’s very simple — if nursing homes aren’t sufficiently staffed, the quality of life and quality of care for residents will suffer,” Mr. DePasquale said.
In addition to requesting the audit a year ago, the Wolf administration began increasing punitive actions against nursing homes after concerns arose over how well it was monitoring care in facilities. That was due to an attorney general’s lawsuit against the Golden Living Center nursing home chain, which has yet to go to trial, alleging deplorable conditions in 36 of the chain’s Pennsylvania homes.
Overall fines and licensing actions imposed for substandard nursing home quality had fallen off drastically from 2010-14, but in its response to the audit, the department said the number of fines increased from 11 in 2014 to 32 in 2015. The number of licensing downgrades increased from nine to 19.
Despite those increases, Mr. DePasquale characterized the department as preferring to encourage improvement by nursing homes instead of punishing them for bad behavior. He did not criticize that approach, but said the state should consider increasing maximum allowable fines as potential deterrents for the worst violators.
He identified multiple instances in which substandard nursing home care was found to have contributed to preventable deaths but the facilities had to pay only several thousand dollars in fines. The maximum fine per day in Pennsylvania is $500, which the report said is far lower than in comparably sized states.
Russell McDaid, president of the Pennsylvania Health Care Association, which represents for-profit nursing homes, said the group is open to discussing changes in thresholds for staffing and fines, but only if the state also considers increasing Medicaid reimbursement rates that the industry believes are too low.
Health Department officials said increases in fines and staffing requirements merit review. A task force of state and national experts that was created last year is expected to provide its own recommendations later this summer on changes the department could undertake to improve nursing home quality.
“It’s very simple — if nursing homes aren’t sufficiently staffed, the quality of life and quality of care for residents will suffer.” — Pa. Auditor General Eugene DePasquale