Auditor finds Vermont falls short on long-term care oversight

By KRISTEN FOUNTAIN

VtDigger

Published: 03-29-2023 5:31 PM

Vermont state regulators have been treating rule-breaking at residential care homes and assisted living residences with less urgency than is required for skilled nursing homes, according to a report released Wednesday by the Office of the State Auditor.

These generally smaller facilities also aren’t getting annual inspection visits that nursing homes do, and as required by state law, the report said.

Plus, the follow-up to ensure problems noted during visits are fixed is also less consistent.

That’s true even though a slightly greater number of older Vermonters live in such facilities — around 3,300 versus just under 3,000 in nursing homes.

“I was really struck by the difference in the model,” state Auditor Doug Hoffer said about the findings. “The whole process is so starkly different then what they do for nursing homes.”

The reason is that the state Department of Disabilities, Aging and Independent Living (DAIL) evaluates the state’s 37 skilled nursing facilities based on requirements set by the federal Centers for Medicare and Medicaid Services. The 114 residential care homes and assisted living residences are only subject to state law, which is less specific about when and how inspections are done.

Between 2016 and June 30, 2022, DAIL inspectors performed 691 inspections of residential care homes and assisted living residences that were analyzed by the state auditor’s staff.

The auditor’s office found that even prior to the start of the COVID-19 pandemic, facilities were only being inspected every two years, rather than every one year as required by law. Also, there were 11 facilities that had not been visited by regulators since 2018, according to the findings.

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In a letter attached to the report, DAIL Commissioner Monica White noted that number had been reduced to seven as of last week.

When problems are found during an inspection or visit, the facility’s staff must develop a corrective action plan that is reviewed by DAIL.

However, the audit found that even in cases where problems “presented immediate jeopardy to resident health or safety,” it took DAIL staff between 54 and 125 days to revisit the facilities and check that the reported steps had actually been taken. In less serious situations, where there was “actual harm” but not “immediate jeopardy,” a return visit was not made half the time, the auditor’s report found.

In contrast, federal regulations require that actions in response to deficiencies found at a nursing home be re-inspected within 23 days for the most serious violations and 60 days for a lower tier.

The most common violations described in the inspection reports were the lack of a written or updated care plan for each resident and a lack of documentation for staff training.

However, the auditor’s office also described seeing more serious issues documented, such as improper lifting of residents that led to falls resulting in injury or death, abuse of residents by staff, and staff giving a patient the incorrect dose of morphine.

When the same violations were found again and again, DAIL did not always use the penalties available, the audit report said.

Those include daily fines, temporarily suspending the admission of new residents and, at the extreme, taking over the facility.

The audit recommends that the Vermont Legislature set stricter guidelines for how the department performs residential facility inspections and require the same timeline for responding to problems and follow-up as what is required for nursing homes.

White, the DAIL commissioner, agreed with many, though not all, of Hoffer’s findings and recommendations.

“We have been aware of and acknowledged the need for increased regulatory oversight of state-licensed long-term care facilities,” White said in a response included in the report.

The department has just received funding this year to add five additional positions within the Survey and Certification Unit of its licensing division, which should allow the unit to do more regular inspections and return visits, White wrote.

However, White disagreed that the state regulations should mimic the federal ones. Nursing homes and residential care facilities offer different levels of care and do not necessarily need the same kind of oversight, she wrote in her letter.

Also, the department needs to weigh its enforcement duties with its responsibility to make sure that residential facilities can continue to exist where they are needed.

“It is important to maintain an adequate system of care, which is part of the consideration when determining appropriate enforcement actions,” she said.

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