Audit Finds NCDHHS Lax With Nursing Home Oversight

By Theresa Opeka
Carolina Journal

The North Carolina Office of State Auditor (NCOSA) released an audit report this week highlighting the lax oversight of the North Carolina Department of Health and Human Services (NCDHHS), Division of Health Service Regulation which oversees nursing homes in the state.

There were three major findings of the report:

• The first found that the Division did not conduct timely inspections of nursing homes between March 1, 2021, and Dec. 31, 2023;
  
• the second found that the Division didn’t complete investigations of nursing home complaints within the timeframe prescribed by state law between Jan. 1, 2019, and Dec. 31, 2023; and,
  
• third, the Division didn’t always verify the correction of nursing home deficiencies identified during inspections of nursing homes between Jan. 1, 2019, and June 30, 2022.

As a result, nursing home residents were at elevated risk of conditions that may have threatened their health and safety.

In reference to finding No.1: Of the 425 nursing homes in the state, 289 (68%) had a late inspection during the stated period; 39 nursing homes went more than 20 months without a state inspection

Per federal Centers for Medicare and Medicaid Services (CMS) guidelines, late inspections are defined as more than 15 months since the prior inspection. As of Dec. 31, 2023, 71 nursing homes were already overdue for their next inspection from the Division. 

Additionally, auditors determined that six of nine (67%) inspections at higher-risk nursing homes were late, exceeding the six-month limit between inspections with a range of 6.1 to 7.3 months.

The audit identified three examples of nursing homes in the report, labeling them Nursing Homes A, B, and C; each went between 20 and 21 months between inspections.

For example, Nursing Home C had 22 deficiencies in a February 2023 inspection.

Inspectors determined that care plans had not been reviewed or updated after residents had fallen, developed pressure ulcers, or had medication changes. One resident suffered six falls since August 2022 without an update to his care plan. Two residents had orders for a clear liquid diet only, but the actual care plans incorrectly called for a regular diet and a mechanical soft diet with thin liquids.

They also found that residents were not being assisted with maintaining good nutrition, grooming, and oral hygiene. One resident did not receive any care from early morning to mid-afternoon when a family member stopped by and found the resident had not been bathed, changed, or gotten out of bed and was soaked in urine. Similar deficiencies were found in the previous inspection from June 2020.

The Division told auditors that there were challenges due to the COVID-19 Pandemic, including higher than normal vacancy rates, high turnover, sickness from COVID-19 itself, and concerns for the health and safety of NCDHHS Division staff.

Auditors recommended that the Division inspect all nursing homes in a timely manner in accordance with all federal regulations and laws, seek necessary resources from the General Assembly to clear its backlog of overdue inspections, and ensure the completion of inspections by mandated federal regulations and laws.

In the second finding, Division management told auditors they had never been able to implement the timelines required by state law due to the large number of complaints that require investigation in conjunction with a lack of resources.  

State law requires the Division to complete complaint investigations no later than 60 days after receipt of the complaint.

Between Jan. 1, 2019, and Dec. 31, 2023, the Division received 35,564 nursing home complaints, of which 17,152 required investigations. Only 10,396 (61%) met requirements. Auditors determined that the Division did not complete an investigation within 60 days for 6,756 (39%) of the 17,152 complaints. In addition, the Division failed to initiate an investigation within 60 days for 6,543 (38%) of the complaints.

Auditors found because the Division’s complaint investigations were not completed in a timely manner, nursing home residents were at an increased risk of suffering from delayed corrective action for conditions that could be life-threatening, abusive, and neglectful.

An cited example of this was March 11, 2022, when the Division received a complaint that a nursing home injured a resident by allowing them to slip and fall from a lift when moving them from their bed to a wheelchair. The complaint stated that the resident had to be taken to the hospital and required surgery. The Division did not complete an investigation of the incident until Aug. 3, 2020 — 145 days after the complaint was made 85 days late. When the Division did complete the investigation, the complaint was substantiated, and the nursing home was required to take corrective action.

The Division had the same recommendation as with the first finding. They also stated they had not completed a formal needs analysis to practically determine the resources needed to comply with state law.

Auditors recommend that the Division initiate and complete all complaint investigations within the time frames prescribed by state law and that a formal analysis be completed identifying the resources necessary to comply with investigative time frames as prescribed by state law. Based on the analysis, the Division should seek sufficient appropriation from the General Assembly to allow it to comply with state law; alternatively, the Division should seek clarification from the legislature as to the Division’s responsibilities for investigative timeliness.

Finally, in the third finding, auditors took a sample of 612 (out of 6,004) citations that the Division issued between Jan. 1, 2019, and June 30, 2022, finding that the Division didn’t verify correction of 224 (37%) of them. They were unable to provide supporting documentation for said corrections.

Of the 224 deficiencies, the Division was required to verify the correction of 193 (86%) by obtaining evidence of correction and 31 (14%) of the deficiencies by conducting an on-site revisit.

One of those deficiencies was the failure to prevent significant medication errors.

In March 2022, the Division cited a nursing home for failing to prevent significant medication errors from 9 of 11 residents sampled during the inspection. Residents did not receive multiple medications, including insulin for diabetes, heart medication for atrial fibrillation, pain medication for respiratory failure, anti-seizure medication to prevent seizures, and medication to prevent pulmonary embolism.

According to Division management, Division branch managers are responsible for ensuring that deficiencies are corrected. Division management did not have formal procedures in place to track the deficiencies in order to perform a documented formal review ensuring the verifications occurred and were documented. Instead, they performed only informal documentation.

Division management also said the Federal Centers for Medicare and Medicaid Services (CMS) does not require the Division to have supporting documentation.

Further, this is not the first time the Division has been found to lack documentation. In 2018, the US DHHS Office of the Inspector General reported the same issue with NCDHHS.

Auditors recommend that the Division verify that deficiencies are corrected per federal requirements, and management should develop and implement procedures to ensure that division staff verify that deficiencies are corrected and documented.

Additionally, auditors recommended that the Division consider developing a plan to respond to pandemics and other times of crisis; increase the unpredictability of nursing home inspections when facilities are surveyed; and, establish a policy to regularly inspect the ten nursing homes in the state that don’t take Medicare or Medicaid funding, are private pay, and not subject to CMS regulations.

Mark T. Benton, chief deputy secretary for Health with NCDHHS, disagreed with the audit, saying CMS concluded that North Carolina met or exceeded all of its annual performance measures, surpassing the performance of most of the southeastern US states.

Theresa Opeka is the Executive Branch reporter for the Carolina Journal.