Evaluators find problems in nursing home oversight

Mat Erpelding

BOISE — Staff from the Office of Performance Evaluations uncovered major human resources problems in a state agency charged with nursing home oversight as well as challenges with placing more individuals with complex conditions, even as Idaho’s elderly population grows rapidly.

Senior evaluators Ryan Langrill and Tony Grange told the Joint Legislative Oversight Committee on Monday that their investigators had uncovered “serious dysfunction” within the Bureau of Facilities Standards, a subsection of the Department of Health and Welfare which conducts surveys of nursing home residents. Surveyors who worked in the office had high turnover rates, and in both 2015 and 2017 only seven of 13 positions were filled. The current vacancy rate is more than 50 percent, according to OPE’s report.

“Nursing home surveyors described the workplace at the division as hostile and demeaning,” the report states. “Surveyors feel berated and belittled; they also believe the work environment explains the ongoing retention problems of the survey team.”

While the Office of Performance Evaluations staff didn’t find evidence that work environment had led to excess fines against nursing homes, they found nursing homes were felt intentionally targeted by bureau staff. Fewer than one in 10 nursing home administrators said they had a high or moderate level of confidence in the nursing home study team, compared to about 45 percent who expressed confidence in the assisted living team and nearly 80 percent in the children’s residential care survey team.

“Our interviews and results from a questionnaire revealed that providers fear and distrust the nursing home survey team,” the report states. “Surveyors reported that individuals on the team intentionally instill this fear.”

The bureau’s workplace issues were so severe that OPE investigators asked to be authorized to perform a follow-up investigation within three months, both to ensure that employees who had cooperated with evaluators didn’t face retaliation and to ensure that problems were quickly resolved.

“Correcting the workplace culture is the most pressing of our recommendations,” Langrill told the committee.

In an official response attached to the report, Department of Health and Welfare Director Russ Barron — who the report indicates began an investigation once informed of the problems in the workplace — said the department is committed to resolving the issues.

“We find it unacceptable that despite our efforts over the last two years, surveyors and nursing home providers feel the work environment and culture continue to be harsh,” he wrote in an attached letter.

“We are currently conducting a workplace assessment to determine strategies to address the work environment and culture.

“We will resolve these issues.”

The report also put focus on the diminishing number of facilities willing to accept patients with complex behavioral and medical conditions, given the lower and relatively flat reimbursement structure they receive from the state.

Idaho’s Medicaid program has a flatter reimbursement system than surrounding states, and OPE found this has had the effect of reducing the number of facilities willing to accept those with complicated behavioral issues.

“Hospitals, residential care providers, and advocates reported to us and to the Legislature that placement in residential facilities is more difficult for individuals with complex medical conditions or behavioral problems,” the report states. “They may remain in hospitals or move out of state to receive appropriate care.”

“Why do we have essentially a flat reimbursement rate, regardless of the complexity of the (patient’s condition)?” asked Chairman Mat Erpelding, a Boise Democrat.

“It’s just the fee structure that the states have chosen to use. Idaho has less variation,” Langrill said.

One issue that OPE found was problematic in the regulatory oversight of assisted living facilities is a secondary class of violations called “noncore violations.” There is no process to appeal a finding that a facility had violated those rules, evaluators pointed out.

Lawmakers and Barron lauded the report, and authorized the agency to follow up on the employment issues over the next three months. It will produce a follow-up reporton other issues in residential care regulation in a year.

Rep. Maxine Bell, a Jerome Republican and longtime chairwoman of the Joint Finance Appropriations Committee, said the report underlined the need to restore funding at the Department of Health and Welfare, which was cut during the Great Recession.

“You cannot sit back and assume that a state agency can do more with less all the time,” she said.

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Evaluators find problems in nursing home oversight