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YELLOW SHEET Office of the State Auditor of Missouri |
Report No. 2000-13
March 1, 2000
The following problems were discovered as a result of an audit conducted by our office of the Division of Aging's monitoring of nursing homes and handling of complaint investigations.
INSPECTIONS FOUND TO BE PREDICTABLE
Our audit determined serious problems with inspections of nursing homes. Many citizen complaints received by our office allege that nursing home facilities were aware, or could predict, when the next inspection would occur. Those complaints further allege that facilities often make temporary or cosmetic changes in their staffing levels, physical environment, and quality of care in an effort to mask underlying systemic problems.
Division of Aging personnel acknowledged that it is not unusual for staffing levels to increase once an inspection begins and that this practice results in a skewed picture of actual facility staffing. Scheduling inspections in a somewhat predictable pattern tends to offset the unannounced aspect of the surveys and inspections and provides facilities the opportunity to make temporary improvements in staffing levels and the condition of the facility to coincide with the expected date of the inspection. During our review we noted several examples of the inspection order and/or inspection dates of facilities being very patterned.
In September 1998, the Division of Aging adopted a revised inspection scheduling policy designed to reduce the predictability of facility inspections. The Division of Aging should continue to identify and implement ways in which the predictability of the inspections could be reduced by varying the chronological order and timing of inspections.
MINIMUM INSPECTION REQUIREMENTS NOT BEING MET/ADDITIONAL INSPECTIONS DO NOT OCCUR
Our review also revealed several other problems related to the inspection process. The Division of Aging has not been able to make the minimum number of inspections required by law, much less perform additional inspections. Nevertheless, the Division of Aging rarely performs additional inspections. It would appear the Division of Aging could identify the chronically poor performing facilities and subject these facilities to additional onsite inspections. Additional inspections may help identify deficient conditions in a more timely manner and help force poor performing facilities to maintain a higher level of care throughout the year. Three examples of inspections not being adequately performed or documented, and/or deficiencies being inappropriately removed from the inspection report were noted. In addition, Division of Aging tended to cite more deficiencies when federal inspectors were present.
FAILURE TO INVESTIGATE COMPLAINTS IN A TIMELY MANNER
The Division of Aging does not always initiate complaint investigations in a timely manner. Complaint investigation reports are not submitted to the central office in a timely manner, particularly for complaints assigned the Springfield, St. Louis, and Kansas City Regional Offices. Numerous other problems regarding complaint investigations were noted at the Kansas City Regional Office including instances where the reporter of the complaint was not properly notified as required by state law. Also, facilities which correct the cause of the violation before the complaint investigation occurs cannot be sanctioned unless there is serious harm or injury.
The division does not study the sanctions imposed on nursing homes to determine which are most effective in bringing these facilities into compliance with standards. According to the division, one of the state's sanctions available, a monetary penalty, is currently too burdensome to be effective. In addition, plans facilities submit to correct sub-standard conditions often were not effective to prevent a repeat deficiency, or the plan of correction was not implemented.
MINIMUM STAFFING REQUIREMENT FOR NURSING HOMES SET ASIDE
Our audit also reviewed the Division of Aging's work as it related to the adequate staffing of nursing homes. Many complaints received by our office alleged facilities were understaffed which resulted in inadequate care provided to their residents. State law requires the Division of Aging to set minimum staffing requirements. However, in September 1998, the division rescinded the minimum staffing requirement which was too low to provide adequate care to nursing home residents. Since there no longer is a minimum staffing ratio which addresses the number and qualifications of direct resident nursing care, this action contradicted state law. The Division of Aging should establish a reasonable minimum allowable staffing requirement that also clearly establishes that additional staffing may be necessary based on resident dependency levels. The audit also recommended the division compare actual staffing hours at facilities to staffing levels recommended by the new system under development.
The audit noted that a statistic, provided by the Division of Aging in a response to an audit recommendation, regarding the number of facilities cited for inadequate staffing (229 of 491, or 47%) is misleading as it also includes cites for staff qualification and training issues. According to a June 1999 report generated by Division of Aging from the Online Survey and Certification Reporting System (OSCAR), only 42 of 492 (8.5%) facilities were cited for inadequate staffing during the most current survey.
MANY DISQUALIFIED FROM WORKING WITH CHILDREN AND MENTALLY HANDICAPPED FOUND TO BE WORKING IN NURSING HOMES
The Division of Aging is required to maintain a listing of persons who have abused, neglected, or exploited the elderly and disabled. Nursing homes, residential care facilities, businesses who hire nurses aides, hospitals, and home health agencies are prohibited from hiring anyone on the employee disqualification listing (EDL). We identified 21 instances in which a nursing home or in-home care provider under contract with the department had hired a person listed on the EDL. The Division of Aging does not always issue a deficiency to facilities that hire persons listed on the EDL. We also noted the Division of Aging does not have adequate procedures in place to identify employers who do not perform criminal background checks.
More than 1,100 persons listed in the Department of Mental Health employee disqualification listing and the Central Registry of Child Abuse and Neglect were working in nursing homes or at in-home care providers. In addition, instances were noted in which persons listed on the Aging and Mental Health listings and within the abuse and neglect registry were working in other inappropriate work settings. These concerns will be addressed in a subsequent report to be issued by the State Auditor.
IMPORTANT: Immediate legislative action regarding at least two major findings of this audit are needed to better insure the quality of care for those dependent upon nursing homes as well as Division of Aging supervision of those facilities.
Current state law allows nursing homes to avoid all fines and penalties if they correct reported violations by the time the division reinspects the nursing home on all violations except those that result in a serious physical injury. In addition, statutory provisions for penalties as they relate to repeat violations or problem homes are inadequate. As a result, penalty provisions are lacking and grossly inadequate.
Also, this audit points out that the Division of Aging is unable to disqualify individuals from nursing home employment who are prohibited from working with children and/or the mentally handicapped. Consequently, it is vitally important appropriate legislation be enacted to better insure the quality of care and safety of nursing home residents.
