By Thomas Goldsmith 

Residents at nine out 10 of North Carolina nursing homes face increased risk of death or injury during emergencies because of lapses in meeting state standards, according to a critical new report from a federal oversight agency.

The inspector general’s office, or OIG, of the federal Department of Health and Human Services produced the report based on a statewide sample of 20 homes visited between December 2018 and May 2019, not long after Hurricane Florence forced the evacuations of nursing homes in southeastern North Carolina.

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Eighteen of the homes in the review racked up 188 violations, including “noncompliance with emergency preparedness requirements related to emergency plans, emergency power, plans for sheltering in place and tracking residents and staff during and after an emergency, emergency communications plans and emergency plan training and testing.”

The unannounced visits also found that homes did not comply with life safety requirements, such as having fire detection and suppression systems and having safe places to store hazardous materials.

The state Department of Health and Human Services accepted some of the Centers for Medicare and Medicaid Services report’s findings and disputed others.

“DHHS is carefully reviewing the OIG recommendations and, as noted in its response to the report, has agreed to implement several of those recommendations,” DHHS communications manager Kelly Haight Connor said in a separate email Tuesday.

Sections of the report gave a scathing account of what CMS called the state’s failure to protect residents.

‘Inadequate management oversight’

“North Carolina did not ensure that selected nursing homes that participated in the Medicare or Medicaid programs complied with CMS and state requirements for life safety and emergency preparedness,” the report said.

“The instances of noncompliance occurred because nursing homes had inadequate management oversight and high staff turnover.”

While the report didn’t specifically address COVID-19 issues, best practices at nursing homes have been under particular scrutiny as COVID-19 has ravaged the state, killing more than 1,400 people in these facilities.

“We know that with congregate living, the virus can more easily spread,” Gov. Roy Cooper said at a Tuesday press briefing. “And this administration is working hard to prevent that and working hard to save lives. And we consider it a priority.”

Mandy Cohen, state DHHS director, cited the state’s record in monitoring nursing-home inspections Monday as part of a national virus-protection initiative to check all such facilities.

“We completed surveys of all of our nursing homes, actually a month ahead of schedule, and continue to serve nursing homes to make sure that inspections are going well there, to make sure that they’re following the protocols that are needed to protect both the patients who are there as well as the staff,” Cohen said.

Centers for Medicare and Medicaid Services – OIG Report Full (Text)

DHHS: CMS inspectors ill-informed

The CMS report further stated that North Carolina lacks a standard life-safety training program for staff of nursing homes, and didn’t conduct surveys on life safety more often than once every eight to 15 months, even at centers facing a higher risk.

In response to the federal report, state DHHS officials said that the federal inspectors were not properly trained or well-informed about some of the health and safety requirements for nursing homes.

“There were a number of items identified as ‘deficient’ by OIG reviewers that trained and experienced state surveyors were either unable to substantiate or did not agree the item was not noncompliant,” DHHS’s Haight Connor said Tuesday.

Generally, state DHHS staff carry out inspections of nursing homes in North Carolina, passing that information on to CMS for use in star ratings or disciplinary actions.

All: More money needed

Among other findings, the report says North Carolina would need more resources to perform more frequent checks of safety and emergency preparedness than those required by CMS. There’s agreement on that point from CMS, the state, and the North Carolina Health Care Facilities Association, a nursing home trade organization.

“As the report highlights, North Carolina’s nursing homes need greater resources and a more stable workforce,” said Adam Sholar, president and CEO of the association.

“Those are critical issues for our nursing facilities and we will continue to advocate for additional assistance from the state and federal government to address these concerns.”

Lauren Zingraff, executive director of the nonprofit elder advocate agency Friends of Residents in Long Term Care, noted that shortfalls in staffing noted in the report can have particularly devastating effects in nursing homes.

Short staffing a factor

“Nursing homes are short-staffed, and have a high turnover rate,” Zingraff said in an email. “Staff are not paid a living wage, are part-time, and without any benefits. They are expected to take care of residents’ needs and it is not surprising (albeit not excusable) that certain safety protocols or policies are neglected.”

Hard-pressed staff may lose track of proper emergency-management techniques as they face over-stretched colleagues, frequent turnover, and little paid training, Zingraff said.

Sampling of nursing homes criticized

Sholar and state officials also took aim at the CMS approach of using a  “nonstatistical sample” to choose 20 from the 427 skilled nursing centers across North Carolina.

Factors that went into the choices included high-risk deficiencies reported to CMS and the threat of environmental phenomena — extreme heat, wildfires and hurricanes — with an eye to the homes’ geographical locations, CMS said.

“We agree with the state that this is not the most effective way to measure the level of emergency preparedness at North Carolina’s nursing homes,” Sholar said.

CMS officials responded that the  agency carried out the audit based on generally accepted standards used by governments, designed to obtain “sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions.”

Rose Hoban contributed reporting to this story.

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Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...