In January 2020, Kimberly Jacob contacted the Iowa Department of Inspections and Appeals with a complaint about an Iowa nursing home.
Her grandmother, Connie Roundy, lived at the Rose Vista Home in Woodbine, and Jacob was concerned she wasn’t receiving adequate care.
The department acknowledged the complaint within days, but it wasn’t until March 25, 2021 – 14 months later — that DIA investigated the matter. By that time, Roundy, who was a former school teacher, seamstress and farm wife, had been dead for six months.
The agency ruled Jacob’s complaint was substantiated and Rose Vista was cited for three regulatory violations, none of which appear to be directly related to Roundy’s care. No fines were imposed.
Jacob says she’s disappointed not only in the handling of the investigation, but in the length of time it took DIA to launch the investigation.
“DIA has a responsibility to execute investigations in a timely manner,” she said. “Failure to do so has serious consequences for our most vulnerable population. My grandma was a beautiful human being and she deserved better.”
According to newly disclosed statistics from DIA, Jacob’s experience is not unique.
As of last month, there were 410 complaints pending against Iowa nursing homes that were at least 30 days old. Of those, 201 complaints – almost half the total number — were more than 120 days old.
In fact, 24 of the pending complaints against Iowa nursing homes are now more than one year old, according to DIA.
“That’s a real problem,” said Toby Edelman, senior policy attorney at the national Center for Medicare Advocacy. “I mean, how can you investigate something that happened 120 days ago? Or a year ago? People are probably not around at that point – the staff, the residents or even the families.”
What’s more, federal officials are now allowing states to simply close out many of their nursing home complaints with no investigation while classifying them as either “withdrawn” or expired.
DIA spokeswoman Stefanie Bond says that after Jacob filed her initial complaint in January 2020, she provided additional information to the agency in February.
Four days later, Bond said, federal officials pulled state inspectors out of care facilities across the country due to COVID-19 and suspended most inspection activity. It wasn’t until Jan. 4, 2021, Bond said, that the feds reprioritized inspections for investigating complaints and recertifying homes. Three months later, she said, DIA inspectors entered Rose Vista Home and investigated three pending complaints against the facility.
State records indicate that by the time Iowa’s nursing home inspectors resumed their investigations, they sometimes faced a significant backlog of previously uninvestigated complaints.
For example:
Ten complaints against Fort Dodge home: In August 2021, state inspectors visited the QHC Fort Dodge Villa and issued a 199-page inspection report detailing 19 regulatory violations found at the facility. That inspection was preceded by 10 complaints against the home – every one of which DIA substantiated during the inspectors’ visit.
One death and four complaints in Exira: In April 2021, a resident of the Exira Care Center in Audubon County was found on the floor in a pool of blood with a head injury sustained in a fall. Two months later, the same woman was again found on the floor in a pool of blood, but this time she was dead.
DIA inspectors didn’t visit the home and investigate either incident until May of this year, 11 months after the death. By that time, the inspectors had four separate complaints against the home to investigate. They cited the care center for 11 regulatory violations, substantiated three of the four complaints, and fined the home $18,000.
Eight complaints against Shenandoah home: In April 2021, state inspectors visited the Garden View Care Center in Shenandoah in response to eight complaints, seven of which were substantiated. A worker at the home told inspectors she watched an aide pull a woman out of a room and drag her backwards across the floor into another room, saying, “Sit down and shut the f— up.”
The inspectors cited the home for 16 regulatory violations, including failure to protect residents from abuse; failure to have sufficient nursing staff, failure to maintain sanitary conditions, failure to provide residents with physician-prescribed supplemental oxygen, failure to provide adequate grooming and bathing for residents and failure to change wound dressings.
Federal officials imposed a fine of $316,140. Because the home didn’t appeal the fine, the penalty was automatically reduced to $205,491.
DIA is ‘working through the backlog’
Bond says the COVID-19 pandemic, which hit Iowa about six weeks after Jacob filed her complaint, is largely to blame for her agency’s backlog of uninvestigated complaints.
She notes that after the federal Centers for Medicare and Medicaid Services, or CMS, suspended inspections at nursing homes, it developed a COVID-19 “focused infection control” process that directed state agencies like DIA to focus their inspections strictly on infection prevention.
As a result, Bond said, complaint investigations were temporarily limited to those involving infection issues and those involving allegations of immediate jeopardy to residents’ health and safety.
That, in turn, led to a growing nationwide backlog of uninvestigated complaints and the inspections that are needed to recertify care facilities, she said.
Currently, CMS is requiring state agencies to reduce their complaint backlogs by 60% and their recertification backlog by 50%.
In Iowa, Bond said, DIA inspectors are “working through the backlog,” and the agency has hired federally certified contractors to help in that effort.
“DIA is diligently working to achieve CMS 2022 performance measurements and ensure quality care is provided to Iowans in health facilities,” Bond said.
Federal work-performance reviews of DIA show that long before the pandemic hit, the state agency had difficulty meeting federal standards for investigating complaints.
Those reviews indicate that between September 2018 and September 2019, DIA fielded 971 nursing home complaints that residents’ mental, physical or psycho-social status were being harmed. “Complaints” include self-reported incidents that emanate from the homes themselves.
Those cases were considered serious enough that a “rapid response” by DIA was required, which meant that an on-site visit was to be made by state inspectors within 10 days.
The agency failed to meet that standard in 631 cases, or 65% of the time. In fact, 41 of those homes still hadn’t been visited by an inspector at the time of the federal performance review, which was concluded in March 2020.
The previous year, DIA fielded 1,041 nursing home complaints that alleged harm. In 646 of those cases, or 62% of the time, the agency failed to conduct an inspection within the 10-day time frame. Six complaints languished for more than 130 days with no inspection taking place.
Ombudsman: The system is ‘overwhelmed’
Iowa Long-Term Care Ombudsman Angela Van Pelt says she’s noticed that when DIA inspectors visit a care facility, they’re now handling multiple complaints, which in itself can slow down the investigation process. The longer it takes to make those visits, she said, the more likely it is that the number of complaints will grow.
And because the staff turnover in nursing homes appears to have reached an unprecedented level, with COVID-19 accelerating staff resignations and retirements, it can be hard for investigators to determine whether the complaints have merit, she said.
“I know our staff is talking consistently about administrative turnover – that in the 30 years they’ve been working, they’ve not seen this sort of shift, in terms of homes going through one administrator after another,” Van Pelt said. “This is just an overwhelmed system right now.”
Van Pelt’s office handles complaints that, generally speaking, are less about medical care and more about residents’ rights, building conditions and resident safety. Her office can typically investigate those complaints within 10 days, if not sooner, she said.
Edelman says some regulators consider complaint investigations to be far more productive than the routine, annual inspections of nursing homes conducted by state agencies like DIA.
That’s because the routine, annual visits often take place within days or weeks of the previous year’s visit, allowing facilities to add staff in anticipation of an inspection, while the complaint investigations aren’t based on any sort of predictable schedule.
In addition, she said, families have become “far more sophisticated” in documenting their concerns through written logs and photographs that can provide valuable evidence to inspectors.
“So ignoring these complaints, or downgrading the complaints, can be a real problem,” Edelman said.
Iowa not alone with complaint backlog
Iowa is not the only state struggling with a backlog of uninvestigated complaints.
In May, the USA Today Network reported that 96% of the complaints filed in the state of New York during the first two years of the pandemic were either ruled unsubstantiated or remained unresolved.
That same month, Arizona’s auditor general issued a report saying the state had placed its nursing home residents at risk by failing to properly investigate complaints of abuse and neglect in care facilities.
The auditor general reviewed 156 high-priority complaints and found that in 73% of those cases, the state had failed to investigate the complaints within the federally mandated timeframe of 10 workdays.
The report also alleged the state’s inspection agency had inappropriately downgraded 98% of its high-priority complaints to a lower priority, artificially extending the federal deadline for investigating them from 10 days to a full year.
At the national level, it has been five years since the inspector general for the U.S. Department of Health and Human Services last studied states’ compliance with the federally imposed deadlines for investigating complaints.
The 2017 study revealed that almost one-fourth of all states had failed to meet performance thresholds for timely, onsite investigations of high-priority complaints in each of the five years studied.
At that time, Iowa was one of four states that failed to meet the standard in four of the five years.
Feds allow some complaints to go uninvestigated
According to the guidance CMS gives to state agencies, serious complaints alleging immediate jeopardy to the safety of nursing home residents must be investigated within two working days.
Complaints of high-priority issues that don’t involve immediate jeopardy are to be investigated within 10 working days.
State agencies like DIA should still “strive to meet these timelines,” CMS told the states last fall, but if they can’t, they should work toward investigating the complaints “as soon as possible.”
As for the less serious, medium-priority complaints, those can be placed on the back burner and investigated during the next scheduled inspection for the facility, which could be a year or more from the date the complaint was received.
In fact, medium-priority complaints that don’t suggest “a pattern of poor care,” and all complaints deemed to be of low priority needn’t be investigated at all, according to CMS. The state agencies are now allowed to simply close out those cases and then classify them in the federal complaint-tracking database as “withdrawn/expired.”
In its written guidance to state agencies, CMS said last fall that it “is very concerned about how residents’ health and safety has been impacted” by state inspectors having less of a presence in nursing homes during the pandemic.
The agency pointed out that due to the pandemic, it waived certain regulations and allowed nursing homes to employ nurse aides for more than four months even if the aides didn’t meet federal training and certification requirements.
As a result, CMS is now asking state inspectors to “pay additional attention” to homes’ compliance with the federal requirement that they have sufficient, competent nursing staff.
The federal agency also wants inspectors to be on the lookout for residents being placed on antipsychotic medications that are unnecessary and are used to simply control residents’ behavior.
Lawmakers consider budget increase for long-term care oversight
Earlier this year, Van Pelt, the long-term care ombudsman for Iowa, lobbied state lawmakers for additional money to add staff and improve her office’s oversight of nursing homes.
The Iowa House approved legislation that would have awarded her office an additional $300,000 – enough money to increase the number of regional ombudsmen working around the state from six to eight and allow for the hiring of one additional staffer.
That would have restored the office to pre-2018 staffing levels, while still leaving it with fewer staff than other, similarly sized states. The bill never made it through the Iowa Senate.
“That definitely was a discouraging moment,” Van Pelt said.
Two years ago, John Hale, a consultant and advocate for older Iowans, said Iowa’s handling of nursing home complaints “paint a picture of an organization that’s failing Iowans.” At the time, he singled out state lawmakers for what he called their lack of oversight.
“The House and the Senate each has a Government Oversight Committee,” he said. “They should be routinely asking tough questions and holding agencies accountable.”
Since that time, state legislators have held no hearings on DIA’s oversight of nursing homes.
Iowa Capital Dispatch is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Iowa Capital Dispatch maintains editorial independence. Contact Editor Kathie Obradovich for questions: info@iowacapitaldispatch.com. Follow Iowa Capital Dispatch on Facebook and Twitter.
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