Illinois nursing home complaints not investigated for more than 3 months amid pandemic that killed thousands of residents

By Joe Mahr

Illinois Department of Public Health Director Dr. Ngozi Ezike talks to reporters during a briefing on COVID-19 at the Thompson Center on April 1, 2020, in Chicago. (John J. Kim / Chicago Tribune)

A month after firing the state’s top nursing home regulator without explanation and disciplining another, the Illinois Department of Public Health acknowledged Friday that the agency did not investigate complaints of neglect and abuse for nearly 3½ months during the coronavirus pandemic.

In a news release, the agency said it had hired a consulting firm and a former federal prosecutor to conduct a “top to bottom” outside review of its Bureau of Long-Term Care. The bureau oversees regulation of nursing homes and other long-term care facilities, which have been tied to more than half of Illinois’ COVID-19 deaths.

A health department spokeswoman said top administrators discovered July 8 that agency personnel had not investigated any of the abuse or neglect complaints it had received from mid-March until June 22 as required by state law. The most serious complaints require an investigation to begin within 24 hours, next-worst within seven days and least serious within 30 days.

The federal regulator of nursing homes, the Centers for Medicare and Medicaid, had said that during the pandemic states should focus on investigating concerns about infection control — which Illinois did continue to do ― as well as serious complaints of abuse and neglect, which state officials acknowledged did not happen when it should have. Regardless, the state law requiring timely investigations of all cases remained in effect.

On July 20, the agency fired Debra Bryars, an agency deputy director who ran the Office of Health Care Regulation, and placed Aimee Isham, who oversaw the Bureau of Long-Term Care, on indefinite paid leave. Isham resigned on Monday, state officials said.

Agency officials did not announce these moves and, when asked about them in late July, would not say why they occurred. Officials said Friday that they wanted to focus on catching up on the inspections, figuring out what happened and deciding how to ensure it didn’t happen again.

IDPH now has investigated 272 allegations received during this period and substantiated “the factual circumstances of 17 of those complaints,” according to the agency’s news release.

“Our top priority as a regulator of long-term care facilities in Illinois is ensuring vulnerable Illinoisans are kept safe by those responsible for their care,” IDPH Director Dr. Ngozi Ezike said in the release. “Anything short of that is unacceptable, and our entire department is committed to getting this right as we move forward.”

The lapse in investigations, the agency spokeswoman said, was based on decisions made by a retired employee who had come back to help out through June 5, in addition to Bryars and Isham. Bryars had been paid roughly $120,000 a year and Isham roughly $110,000, records show. Neither has responded to messages.

The advocacy group AARP Illinois said the agency’s delay in explaining what happened highlights broader failings by the state to prioritize Illinois’ aging population.

“On behalf of family caregivers, the lack of transparency displayed here is unacceptable and heartbreaking for families across Illinois. We respect the investigation, but the department’s failure to protect the health and safety of Illinois’ most vulnerable population is inexcusable and has gone on for far too long,” AARP Illinois director Bob Gallo said in a Friday statement.

In its Friday news release, IDPH said Manatt Health Strategies will conduct “a top-to-bottom review” of the bureau that oversees long-term care facilities, “with a focus on recommending best practices to ensure proper licensure and oversight activities.”

The agency said it also hired A. Courtney Cox, a former federal prosecutor, “to take a closer look at specific investigations IDPH conducted into complaints made concerning long-term care facilities during the COVID-19 pandemic. This review will inform IDPH’s efforts to improve existing procedures.”

The Tribune for weeks has been pressing the agency to release documents that could explain why, in late July, it removed Bryars and Isham. On Friday, after issuing the release, the agency told the Tribune it would not release additional records, citing exemptions in state law for preliminary drafts and attorney-client correspondence.

The state health department, designated by law as the state’s top regulator of nursing homes, is also the state’s lead agency fighting COVID-19. A Tribune investigation early in the pandemic found a high percentage of Illinois nursing homes had been cited for poor infection control practices, prompting advocates to warn that the state needed to aggressively monitor and fight the virus.

Gov. J.B. Pritzker and top leaders have repeatedly said their swift actions limited the virus’ spread and saved lives. Yet the agency’s efforts have at times been broadly criticized as too timid and uncoordinated. Facilities complained they needed help getting more staff and protective gear as infections swept through hundreds of facilities.

The virus has been blamed for killing more than 4,000 Illinois long-term care residents and workers, at last count. Recent federal data showed that the state’s death rate for nursing home residents, at nearly 48 deaths per 1,000 people, puts Illinois among the worst third of states and territories.

Public criticism of the state’s oversight efforts has waned as deaths tied to long-term care facilities began dropping significantly in recent months, from nearly 500 a week in May to now fewer than 100 a week. Homes are now beginning to accept visitors again.

Full Article & Source:
Illinois nursing home complaints not investigated for more than 3 months amid pandemic that killed thousands of residents

Lawmakers outraged over lack of investigation in nursing home complaints

The numbers of nursing home complaints that are not fully investigated have left Minnesota lawmakers quietly shocked and outraged.

The Minnesota Health Department performed on-site investigations of just 10 percent of the 3,400 complaint allegations it received from the public about nursing home and home-care treatment last year, according to the agency’s statistics.

And when nursing homes or other facilities self report allegations, the numbers from fiscal year 2016 were even lower. The agency only did on-site inspections of 102 allegations — less than 1 percent — of the nearly 21,000 allegations it received from providers’ reports.

“This is one of the worst performance reports I’ve heard in my 18 years,” Sen. Jim Abeler, R-Anoka told state officials. “As a state we are failing with this….I don’t often get shocked anymore but you caught my attention.”

MN Commissioner of Health Dr. Ed Ehlinger

In committees and subsequent interviews, the agency agreed the numbers deserve attention.

“It is a high priority. This is an issue that we’ve had to deal with,” Health Commissioner Ed Ehlinger told the Pioneer Press.

The number of vulnerable adults receiving care and the ease of lodging complaints have both grown in recent years, resulting in an exponential increase in the number of complaints the department takes in.

In 2010, the state’s Office of Health Facility Complaints received fewer than 500 maltreatment complaints from the public. Last year, that number was nearly 3,500. Six years ago, providers reported 3,100 possible issues. Last year, they reported almost 20,800.

The influx has prompted the agency to triage the complaints that come in. Complaints of actual harm, potential for harm or widespread problems which could lead to immediate jeopardy quickly rise to the top, said Assistant Health Department Commissioner Gil Acevedo.

But that leaves the department unable to immediately attend to other issues.

“Thousands of complaints are not investigated so maltreatment continues, and less severe issues may escalate to more serious harm,” the agency said in a budget request this year. Those uninvestigated complaints in the last year included more than 4,000 falls, nearly 2,000 complaints of emotional or physical abuse by staff and nearly 3,000 “unexplained injuries,” the department said.

“We know that this is not acceptable,” Acevedo told a senate committee. “The volume of complaints that are coming in pretty much overwhelms our staff.”

TIME DELAY

Even when the agency does an on-site investigation, the process takes a while.

“Because of the time it takes to complete investigations, the public does not know about complaints occurring in facilities where their loved ones live,” the agency said in its budget request.

Acevedo highlighted for a senate committee a case the state looked into last year, from a Gracewood senior living facility in Hugo.

From the investigative report on the incident: “A white powdered substance was spread under the client’s nose and the same white powdered substance was on the table placed in three straight lines. Client #2 was experiencing arm tremors. The song ‘Cocaine’ by Eric Clapton was playing in the background.” The white powder, it was discovered, was powdered sugar.

That resident was suffering from Alzheimer’s disease and “was unable to report maltreatment due to severe memory impairment,” the investigative report said. But a staffer at the facility recorded the incident and shared the video.

In another incident, a client was recorded on the toilet and yelling “you guys are going to hell” at a staffer, and a staffer yelled back “we’ll see you there.” In a third recorded and shared incident, a client was videotaped holding an empty alcohol bottle “while another unidentified staff member was pushing the client’s wheelchair, with ‘rock music’ playing the background.”

“The facility was aware about this but did nothing to correct it,” Acevedo told senators.

But the report raised questions.

 Sen. Karin Housley, R-St. Marys Point

“You said that complaint came in May,” Sen. Karin Housley, R-St. Marys Point, asked the assistant commissioner at the committee meeting.

“Yes, ma’am,” Acevedo replied.

“And the report was just posted yesterday?” Housley asked on Feb. 1.

“Yes, ma’am,” he said.

According to the health department, the initial complaint was received May 9 and considered serious enough to warrant a site visit. That two-day visit occurred in mid-June. The investigation continued until Aug. 24. The investigator informed Hugo Graceland that it found a violation of state statute in early October. While the investigation became public information on Dec. 20, it wasn’t posted onto the state’s website until Jan. 31, 2017, because of a backlog in web postings.

Although the state took months to publicly post the report, Hugo Graceland did not wait for action, according to Kari Bina, regional director for the group that operates a dozen Minnesota assisted living facilities, including Hugo Gracewood.

“We didn’t find out about this incident until the state walked through our door,” she said. Once the state officials arrived in June, the facility conducted its own investigation and “staff members that were involved were terminated immediately.”

NEXT STEPS

As the number of complaints rose and the percentage of state officials who could investigate declined, the state took steps to address some of the issues.

The state changed the leadership of the office overseeing investigations, began work to streamline the investigation process and adopted new methods to help prevent problems.

“We recognize that we have not been able to meet the needs that are there in the community. We recognized it several years ago and, actually, it has led to some major changes,” said Ehlinger, the health commissioner.

The governor’s budget also proposes a state increase in funding for the health facility complaint office over the next four years, accompanied by a request for more federal funding for investigations and higher fees paid by nursing home and home care providers.

Patti Cullen, president and CEO of Care Providers of Minnesota, which represents nursing homes and other care and housing providers, said the providers see the need to increase the state complaint-investigation work.

“We’re supportive of that, even if there are going to be increased fees on our people,” she said.

Sen. Jim Abeler, R-Anoka

Abeler, the state senator from Anoka and a longtime expert in health and human services, said he was not sure that increasing the budget would solve the problems.

“I don’t think they use the money they have well,” he said.

Meanwhile, the state will continue to work to improve.

“We are far from where we need to be,” Ehlinger told senators. “We are far from where we want to be.”

Full Article & Source:
Lawmakers outraged over lack of investigation in nursing home complaints

Pa. halted anonymous nursing home complaints for 3 years, audit finds

Pennsylvania Department of Health Secretary Dr. Karen Murphy (left) and Auditor General Eugene DePasquale on Tuesday discussed the results of an audit of the state's nursing home system.
Photo by Brad Bumsted | Tribune-Review

HARRISBURG — The Pennsylvania Department of Health risked “residents' safety” by refusing to accept anonymous complaints against nursing homes for almost a three-year period, Auditor General Eugene DePasquale said Tuesday. 

Halting anonymous complaints violates federal policy and is “a decision that is absolutely breathtaking,” DePasquale said at a news conference. He said he suspects it was “an action intended to silence critics.” 

It occurred from 2012-14 under the former administration of Republican Gov. Tom Corbett.

Michael Wolf, who became acting state Secretary of Health in October 2012, was nominated by Corbett in April 2013 and confirmed by the Senate in May 2013. Now a vice president of a health care management company, Wolf could not be reached Tuesday for comment. 

DePasquale, the state's fiscal watchdog, said his auditors found no records indicating the rationale for the decision to stop accepting anonymous complaints. 

The audit covered January 2014 through October 2015, a total of 22 months, DePasquale's staff said. During that period, 4,062 complaints were filed against for-profit and nonprofit nursing homes. The complaints resulted in 47 sanctions, 32 of them monetary, according to DePasquale's office. 

Dr. Karen Murphy, the current agency secretary and Democratic Gov. Tom Wolf's appointee, said the department resumed accepting complaints from anonymous tipsters in 2015. Complaints increased 63 percent after the agency rescinded the policy of not accepting anonymous complaints, the audit said. 

Asked what percentage of anonymous complaints were validated, Murphy said about 10 percent. 

While the agency fully cooperated with the audit and many of the recommendations have been implemented, it still has “work to do” in assuring appropriate staffing levels, DePasquale said. 

The level of care provided to 80,000 Pennsylvanians in nursing homes is directly affected by staffing levels, Depasquale said, and the state health department did little to enforce a law requiring 2.7 hours of direct nursing care per day for each resident. 

In 7,325 instances of the agency completing a nursing home survey, it issued 13 citations — “an unbelievably low number,” DePasquale said. 

He cited examples of insufficient penalties, such as a resident with a history of wandering, who fell down a flight of stairs in a wheelchair. Staff responded immediately, but the patient later died in a hospital. The facility was cited for violations and fined $4,000. 

In another instance, after a complaint from a family member that a patient was “dirty, frail and unresponsive,” the person was found to be malnourished and dehydrated. The patient was receiving too much anti-psychotic medication, DePasquale said, and later died in a hospital. 

As a matter of policy, the names of the homes are not cited in the audit, DePasquale said. 

Murphy said citations issued to homes are publicly available on her agency's website. 

Pennsylvania's maximum civil monetary penalty is $500 per day. 

A comparison of selected states in the audit showed the maximum penalty is $100,000 in California, $10,000 in New York, $10,000 per day in Texas, and $25,000 in Illinois, which may be doubled. 

Russell McDaid, president and CEO of the Pennsylvania Health Care Association, an advocacy group for nursing homes and their residents, applauded Murphy for requesting the performance review audit from the auditor general, including ways the department can improve its enforcement. 

However, McDaid cautioned that “more stringent penalties do not alone improve care.” 

“It is important to note that when any sanction or penalty is considered, the most important goal is to identify the practice in question, take steps to correct the practice and ensure that any sanction does not jeopardize the facility's ability to improve resident care, comfort and safety,” he said. “Taking financial resources away from the bedside does not improve resident care.”

Full Article & Source:
Pa. halted anonymous nursing home complaints for 3 years, audit finds