Report No. 18-18, Audit of the Office of Health Care Assurance’s Adult Residential Care Homes Program
From Hawaii State Auditor, Report 18-18, November, 2018
In Report No. 18-18, we found that the office renewed licenses without first completing the relicensing process, substituted much less rigorous unannounced care home visits for statutorily required inspections and issued licenses without even inspecting or visiting the facilities. About half of the 214 care homes we sampled were allowed to operate in 2017 with either an expired license or a license hastily issued before all required steps of the relicensing process were completed.
In its 2018 report to the Legislature, OHCA stated that all deficiencies identified during an inspection must be corrected before a care home facility is relicensed. However, since OHCA does not conduct followup visits to verify implementation of the Plan of Correction, there is no way to determine if corrections have in fact been made. In 2017, 116 care homes in our sample were relicensed before the inspection process was completed.
IN REPORT NO. 18-18, Audit of the Office of Health Care Assurance’s Adult Residential Care Homes Program, we examined the Office of Health Care Assurance’s (OHCA) relicensing process. That process is integral to OHCA’s ability to ensure that care homes maintain certain quality of care standards to safeguard the health, safety, and welfare of care home residents. Relicensing is a time-consuming effort, which relies heavily on the judgment and discretion of the office’s nurse consultants who inspect adult residential care homes (ARCHs) and expanded adult residential care homes (E-ARCHs) and identify deficiencies in quality of care standards.
What We Found
We found that OHCA renewed licenses without first completing the relicensing process, substituted much less rigorous unannounced care home visits for statutorily required inspections and issued licenses without even inspecting or visiting the facility. About half of the 214 care homes we sampled were allowed to operate in 2017 with either an expired license or a license hastily issued before all required steps of the relicensing process were completed. Of these, OHCA had yet to complete the inspection process from 2016 for 22 care homes. In 2017, eight care homes in our sample had 20 or more deficiencies with certain quality of care standards, but OHCA relicensed them before those deficiencies were resolved. Most of the time, OHCA simply renewed a care home’s license.
In addition, we found that OHCA has no written guidelines for enforcement if licensees cannot or will not comply with quality of care standards. For instance, OHCA neither ranks specific care home deficiencies according to severity nor does it have guidance on the number of deficiencies that would disqualify a care home from license renewal. This may at least partially explain why OHCA did not sanction or fine a single care home nor did it completely terminate a single care home license in the 10-year period from 2007 to 2017, even for care homes with substantial or repeat deficiencies.
Why Did These Problems Occur?
We found that OHCA’s primary objective appears to support the continued operations of care homes, not to ensure the health, safety, or welfare of the facilities’ residents as mandated by statute. Perhaps, as a result, we found that OHCA lacks the basic organizational infrastructure necessary to guide and support its relicensing activities. For instance, it has no uniform system to track inspections and review and update information. In addition, OHCA has no internal timelines or deadlines for each step of the relicensing process to ensure tasks are completed within a specific timeframe, and ultimately, before a care home’s one-year license expires.
Why Do These Problems Matter?
“Assurance” is the “A” in OHCA. Assurance assumes that care home residents’ health, safety, and welfare are protected. However, relicensing a care home before the inspection process is completed or doing so without verifying compliance does not provide assurance. And failure to fully define and use enforcement authority do not provide assurance. To the contrary, these circumstances, which we found to exist at OHCA, likely increases the risk to the health, safety, and welfare of care home residents.
Read … Summary or Full Report
* * * * *
DOH OFFICE OF HEALTH CARE ASSURANCE RESPONDS TO STATE AUDIT
News Release from DoH, Nov 15, 2018
HONOLULU — The Office of the State Auditor released its audit of the Hawai‘i Department of Health’s Office of Health Care Assurance (OHCA) today, identifying areas for improvement to ensure the health, safety, and welfare of residents in adult residential care homes.
“Understandably, some may conclude from this audit that those in adult residential care homes were at risk and unsafe in 2016-2017. Timely inspections and reports are indeed important in assuring the quality of care,” said Dr. Bruce Anderson, director of the Department of Health. “However, it is important to underscore that any risks to the safety, health and well-being of those in adult residential care home are immediately investigated and appropriate action is taken. Further, significant improvements in operations have been made during and since the audit period.”
OHCA conducts inspections and visits, both announced and unannounced, of licensed adult residential care homes and expanded adult residential care homes on an annual basis.
Whenever OHCA surveyors identify potential abuse or neglect, these incidents are immediately reported to Adult Protective Services (APS), another state agency, for a thorough investigation. APS is part of the Adult Protective and Community Services Branch of the Hawai‘i Department of Human Services. In addition, OHCA also conducts timely investigations of consumer complaints or suspicions of abuse or neglect referred from APS. The inter-departmental collaboration has resulted in 277 referrals for all types of facilities between the two entities over the past five years.
“As the need for cost-effective care for our aging population continues to grow, OHCA’s role in assessing the quality of care at adult residential care homes will become even more important,” Anderson said. “Protecting the health, safety, and welfare of kūpuna and those with disabilities who live in residential care homes is an essential requirement we take very seriously. Addressing the audit findings and implementing their recommendations, including the submission of more timely inspection reports and developing clear policies and procedures related to monitoring and enforcement, will better prepare us for the future.”
The audit reviewed activities that took place from January 2016 to December 2017, which included the period in which OHCA was facing the challenge of inadequate staffing to meet its statutory obligations. Adequate staffing became a priority funding request and both the Governor, and the Legislature recognized this need and approved additional positions in 2017.
OHCA is also implementing new or revised procedures aimed at providing improved and structured management oversight on the inspection processes and enforcement.
“These new staff positions along with clear policies and procedures will ensure the sustained support needed to meet current and future workload requirements so that inspectors can consistently complete inspections and the license renewal process in a timely manner,” Anderson said.
Despite past challenges, OHCA conducted all required annual inspections in 2017, is on track to complete all annual inspections in 2018 and continues to make improvements in its operations. Current actions now underway to improve operations, which are consistent with the auditor’s recommendations, include:
- Development of a management information system to track workload and staff assignments;
- Transition from a paper-based system to a fully electronic inspection process;
- Development of an automated system to post electronic inspection reports online; and
- Implementation of updated, revised, and new policies and procedures that ensure operational consistency.
“OHCA made significant improvements since 2016 to live up to their mission of assuring that care homes in Hawaii are safe,” Anderson said.
The audit, including DOH’s full response, is available at the Office of State Auditor’s website at http://auditor.hawaii.gov.
# # #
PDF: JOINT SENATE-HOUSE INFORMATIONAL BRIEFING: AUDIT REPORT OF THE OFFICE OF HEALTH CARE ASSURANCE ADULT RESIDENTIAL CARE HOMES PROGRAM