By Ashley Fredde
State lawmakers are proposing a bill they say would reduce administrative burden and redundancy for inspections in adult care homes, the places that manage the care for some of the state’s most vulnerable residents.
“Adult care homes” have a specific designation in North Carolina. They’re places where the housing management provides 24-hour scheduled and unscheduled personal care services for people — often seniors and people with disabilities — who need help with their medications or assistance with personal care tasks such as grooming, dressing or getting their meals.
The bill, SB 863 “Streamline Adult Care Home Inspections,” would require inspectors — whether from the state, local health department or other authorities — to accept results of a previously passed inspection if it had been done within three months, rather than conduct a new inspection.
“I’ve been out visiting a lot of facilities, and one of the things I heard when I visited folks is how many inspections are done and how much duplication there is,” Sen. Jim Burgin (R-Angier), the bill sponsor, told the Senate Health Care Committee last week.
“We’ve got to make sure that the safety of the residents at all of our facilities, that needs to be the number one priority,” he said.
“[Facility operators] tell me it takes a lot of their people just to deal with not only the inspections, but also the paperwork and the follow up when they have an inspection done,” he added.
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The proposed measure is emblematic of many bills introduced by members of the General Assembly in that it seeks to make it easier for businesses to function. But advocates for seniors and people with disabilities warn that reducing opportunities for oversight could put vulnerable residents at risk. And they expressed concern that the adult care home industry in North Carolina is evolving from traditional, locally run mom-and-pop facilities to faceless companies run by opaque corporate entities.
Reducing duplication
When asked about the bill, Burgin argued that many of the inspections were repetitive.
For example, he referred to a document where one facility had aggregated data about its inspections. The document noted that the facility had been inspected for pests or hot water temperature several times by different organizations over one year.
Committee member Sen. Julie Mayfield (D-Asheville) pushed back against the idea that the inspections might be redundant and expressed concerns about broad language in Burgin’s bill.
Clarifying that the intention of the bill is not about quality of care, Mayfield asked, “This is about the safety of the environment in which they’re living and inspections related to that, right?”
“There might be what people, what agencies are supposed to do, but then what they actually do,” Mayfield said, referring to different agencies that may have overlapping oversight.
Burgin told committee members the intention of the bill was to reduce the number of annual and routine inspections, and it was not intended to keep inspections from happening when there are complaints or disallow follow-ups when inspectors find deficiencies.
“I hate to think we’re duplicating government services because we think that the first government service isn’t doing their job adequately,” bill co-sponsor Sen. Amy Galey (R-Burlington) added during the committee discussion. “I think that there’s other ways to resolve that issue besides scheduling another entity to come and do the same work.”
What’s the difference between a nursing home and an adult care home?
In North Carolina, “adult care” refers to the kind of residential care providing services for people who don’t need skilled medical attention, but can’t live without 24-hour supervision. Residents receive room and board, some activities, medications given by staff, transportation to medical appointments and, as needed, help with bathing and toileting and other activities of daily living.
A nursing home or “skilled nursing facility,” regulated by the federal Centers for Medicare and Medicaid Services, offers care by a registered nurse, under a doctor’s supervision, after illness or for chronic conditions. Some residents stay for shorter periods in nursing homes for speech, occupational or physical therapy.
Source: Resources for Seniors
Different agencies, different roles
Opponents argue that it isn’t the same work, and that though inspections may appear repetitive, many are conducted by different agencies and look for different things.
For example, the Division of Health Services Regulation conducts annual licensure inspections focused largely on resident care, staffing, medication management and regulatory compliance. The agency’s construction section conducts biennial inspections related to physical plant requirements and life safety standards, such as fire protection systems and building code compliance.
“When they’re doing an inspection, most of what they are focused on is the care the residents receive, and is the care that they’re provided consistent with the regulations that impact that,” said Bill Lamb, who spent a large part of his career at DHSR. He also is treasurer and former executive director of Friends of Residents in Long Term Care. And “they’ve got staffing issues,” he added, which can mean annual inspections “can actually stretch out to 18 months.”
Layered on top of that, county departments of social services also conduct annual monitoring visits aimed at ensuring that facilities are operating in accordance with state rules and adequately caring for residents.
Additional inspections may come from local fire marshals to check sprinklers, kitchen safety and fire doors, while health departments might check on food safety. Inspectors from each of those agencies are trained to catch issues within their area of expertise, but they might also catch wind of an issue outside their area.
“All that is not to say that [DHSR inspectors] don’t go in the kitchen and look at some things, that they don’t check to see the fire extinguishers are up to date,” Lamb added. “But they’re not taking a deep dive into the kitchen or fire code, and so they’re different functions.”
Possible oversight gaps
The handout Burgin showed the committee outlined the different agencies that had inspected one facility over the course of a year and what was inspected at the time.
But when broken into categories, those different functions begin to emerge: building and fire safety, food and sanitation, resident care and rights, environmental and safety systems.
“With the building and the safety, it’s very different,” said Hillary Kaylor, a regional ombudsman with Centralina Area Agency on Aging. “They work with them when they’re opening a building, they’ve done a modification, or a renovation, or had something they had to bring up to code that would be really different than an adult home specialist going out and doing their [regular] surveys.”
She said each discipline has its own specialty.
“They’re not all housed under the same realm either,” she said. “They have nothing, or very little interaction with the local fire marshal, the health department — totally separate.”
There can also be variability across counties in local codes when it comes to fire marshal inspections or health departments, Kaylor explained. That could create complications if the agency conducting the inspection is from the state or another entity not familiar with local codes.
“They don’t all report into one big system and everybody sees everything everyone does. That’s not how it works,” Kaylor added.
Tweaks ahead
Ben Popkin, a health care lobbyist who volunteers for the Friends of Residents in Long Term Care, said that in the past, if the quality of an adult care home was poor, the local owners would hear about it from residents’ relatives in the grocery aisle or at church.
“We’ve shifted to a time where there’s private equity companies increasingly taking ownership and seeing these as places where they can return a profit, which is their goal for their investors, but sometimes not necessarily keeping the best interests of these paying residents there,” Popkin said during the committee meeting.
Afterwards, he expressed concern that the language of the bill, as it was presented, was overly broad, something that Burgin told the committee he would be willing to alter.
“It’s always important that the words reflect the intention,” Popkin said. “It’s excellent to hear from the bill sponsors [that] their intention is to reduce redundancy, try to streamline things, but of course, you know the proof is in the pudding.”
Nearing the end of the committee meeting, Mayfield asked if the subject was better suited for a study committee, something that Burgin said he was not willing to consider at the time.
“This bill does what a lot of the bills that we do up here, it gets people talking,” Burgin said. “So I assure you that there’s going to be more conversations, and I doubt that it will be in the exact same form when it is adopted.”
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