Inspections no surprise for care home operators

By Lynda Arakawa
Advertiser Capitol Bureau

A year and a half after the state Department of Health decided it would conduct unannounced inspections of adult residential care homes, the rules covering those inspections are still not ready.

State officials continue to notify care home operators in advance of their annual inspection, a practice advocates for the elderly and disabled say compromises the process to detect abuses and substandard care.

State health officials acknowledge the department could have allowed unannounced inspections by waiving the current rule, by which care home operators are allowed to know which month and day of the week or the week of the month department officials will visit. Care home operators are told about inspections about three months in advance.

"Unannounced inspections provide a more effective tool to get a more clean and comprehensive snapshot of the caregiving environment and the care-home business," said Joe DeMattos, associate state director of the Hawai'i office of the American Association of Retired Persons. "Most care home operators are excellent (and) provide really, really good care, but there also exists the possibility of a care home operator cramming for an annual inspection the way some of us used to cram in college for a final exam."

Department of Health Director Bruce Anderson, who ordered in November 1999 that inspections be unannounced, said: "The specter of an unannounced inspection keeps everyone on their toes, and I think serves as a deterrent to those who might otherwise not consistently comply with our requirements in our rules."

He said because the department was changing an important policy, he believed it was important to get public comment "prior to unilaterally adopting a policy that may have significant impact on care-home providers."

"But having said that, had I known that it was going to take as long as it has to adopt the rules, we may have considered deleting this requirement earlier," he said.

There are about 665 adult residential care homes in Hawai'i that care for almost 4,000 people.

'Warrentless search'

Unannounced inspections have been a prickly issue between the department and care home operators, most of whom oppose it. The Alliance of Residential Care Administrators and other local care home associations have called unannounced inspections "a warrantless search" that violates the constitutional rights of care home operators and their clients. Some say unannounced inspections will disrupt doctor visits, activities or other appointments scheduled for residents.

"If authorities like the policeman or anybody else has the right to go to their house at any time, the most law-abiding citizen will question that rule," said Alliance of Residential Care Administrators president Mariano Apuya, who said care home operators are not vehemently opposed to unannounced visits but want the current practice to continue. "And second, it's not a good tool to enforce compliance. ... It is more a punishment for those people doing good jobs than those doing bad jobs. This is burning a house to kill a rat."

But advocates say while most care homes provide good services, unannounced inspections are necessary to catch those that do not.

"I feel that a majority of (care homes) are run well and the patients are being cared for properly," said Folly Hofer, a retired nursing director and legislative chair of Kokua Council, which advocates on behalf of seniors, children and families. "But if someone were coming to your home you wouldn't have damaging materials left out. There are areas that you wouldn't be able to see if people were advised that a visit was being made.

"With announced visits, it's possible to cover up or hide inappropriate treatment of patients or to curtail it temporarily, whereas with unannounced it's more likely that improper treatment or neglect could be detected."

Following other states

Performing unannounced annual inspections of care homes is a common practice nationwide, said Ed Sheehy, vice president of state legislative and regulatory affairs at the Assisted Living Federation of America, which represents assisted living and other care providers. Sheehy said the initial inspection to license a care home is usually announced, but inspections to renew licenses are typically unannounced.

"It sounds like they (Hawai'i health officials) are going in the direction that most states do it," he said.

DeMattos said care homes in states such as Arizona, California, Nevada and Washington are subject to unannounced inspections at least every one to two years.

Health officials can and do make unannounced inspections to follow up on complaints or deficiencies found in annual visits. But other advocates say that's not enough and that often people don't know where to send complaints.

"You don't want to wait until a problem is reported or announced," Hofer said.

Community awareness is slowly growing about elderly and patient abuse and neglect. Last year, a Pearl City residential care home operator was convicted of manslaughter for the death of a 79-year-old woman who died of an infection resulting from neglected bedsores. While it is not clear that an unannounced inspection would have revealed such neglect, such cases are putting new pressure on the state to more aggressively monitor care home conditions.

Licenses revoked

Most adult care is provided in private homes in Hawai'i and the owners are licensed to care for a handful of residents. They are typically cheaper and most provide less skilled care than nursing homes, which are subject to unannounced inspections under federal law.

The Department of Health revoked the licenses of two care home operators — including the convicted Pearl City care home operator, Raquel Bermisa — last year and revoked two licenses so far this year, said Dianne Okumura, section supervisor of the office of health care assurance section.

Unannounced inspections were among a series of rule changes announced by the Department of Health in 1999. They indicated the rules would be adopted in 2000, but the document is just now on the verge of going through the public hearings required before adoption. Officials have been working with care home operators, advocates and others to revise the rules for about two years.

Helen Yoshimi, chief of the state Office of Health Care Assurance, which licenses and oversees care homes, attributed the delay on the revised rules to an increased workload and few resources. She said the rules should be adopted by the end of September.

But she said in the meantime the department has already waived a rule on hallway width requirements, which care home operators have complained about. She acknowledged the rule requiring announced inspections could be waived as well.

Court challenge feared

Anderson said by waiving the rule on unannounced inspections, it could invite a court challenge.

"Had I waived that requirement, and we had found a problem at a facility through an unannounced inspection, I would guess that the defendants in the case would have some justification in saying that we were not conforming with our own rules and that we had not gone through public hearings on that change," he said.

Anderson said the new rules will give the department the flexibility to conduct unannounced inspections, but that not all inspections will be surprise visits because the department does not have enough people.

"I think the public can be assured that we will be doing sufficient unannounced inspections that care home operators will be consistently providing quality care," he said. "Certainly, it will be a better situation than it is now where inspections are routinely announced."

You can reach Lynda Arakawa at 525-8070 or larakawa@honoluluadvertiser.com.