California Department of Public Health to Require Its Inspectors to “Adopt” a Nursing Home and Serve as Consultants to Nursing Home Operators

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Last week – while the staggering death toll for California nursing home residents from COVID-19 surpassed 2,000 – a top official at the California Department of Public Health (CDPH) testified at separate Assembly and Senate oversight hearings on its plan to reform nursing home oversight.

Inconceivably, the central feature of CDPH’s plan is to turn hundreds of its nursing home inspectors into free, part-time consultants to the very same nursing homes they are required to inspect and regulate. It’s calling this plan the “Adopt a SNF Model.”

CDPH presented its plan at a June 9 hearing by the Assembly Committees on Health and Aging & Long-Term Care and a June 10 hearing by the Senate Special Committee on Pandemic Emergency Response. The hearings examined what went wrong in California skilled nursing facilities and with the State’s response and what lessons have been learned.

So what did CDPH have to say about what went wrong?

Remarkably, nothing. At both hearings, Heidi Steinecker, the Department’s witness, credited the Department with taking resourceful, bold actions at every stage of the pandemic to keep nursing homes safe. There was no mention of the catastrophic death toll or acknowledgment of the immense suffering residents and their families have endured.

Indeed, Ms. Steinecker claimed that the death rate in California nursing homes was “so low” (23rd in the nation) due to its vigilant oversight of nursing homes.

Moreover, Ms. Steinecker testified that, due to the Department’s great success, the Trump Administration recently called her inquiring about “what we’re doing differently than other states and how they can replicate it in other states as a model.”

What is the “Adopt a SNF Model”?

According to CDPH, the Adopt a SNF Model would reform the quality and safety oversight process to include continuous presence in skilled nursing facilities to create a consistent compliance culture.

Ms. Steinecker testified that CDPH would provide this continuous presence by assigning each of its inspectors to two-to-three nursing facilities where they would check-in daily, visit weekly, train the facility staff and be part of each facility’s safety and oversight group. Inspectors would also continue to carry out annual inspections of nursing homes and conduct complaint investigations as they do now.

Additionally, Ms. Steinecker claimed that the “Adopt a SNF Model” will completely change and reform how nursing home oversight is conducted throughout California and then the nation.

Is the “Adopt a SNF Model” an innovative reform?

No, just the opposite. It is a new name for the disastrously ineffective system the nation used to monitor nursing homes before Congress enacted the Nursing Home Reform Act of 1987.

Prior to 1987, federal policies required states to consult and collaborate with individual nursing homes on improving quality. Congress got rid of this model in 1987 after the acclaimed 1986 study by the Institute of Medicine – Improving the Quality of Care in Nursing Homes – found that the inherent conflicts of interest caused by directing inspectors to be both partners with nursing homes and their regulators had seriously compromised enforcement of care standards and contributed to the scandalously poor care in nursing homes throughout the nation during the 1970s and 80s. Its report stated:

The committee believes that current federal policies requiring consultation undermine state agency efforts to eliminate substandard providers and deter marginal facilities from repeating violations. Federal and state procedures for enforcement should be modified to reorient the program toward enforcement rather than consultation and to encourage states to adopt a stronger enforcement posture. 

One does not need to be an expert on oversight to understand the fundamental conflict created by requiring inspectors to assess quality in facilities where they are partners in quality improvement plans and mentors of facility staff. The potential for conflicts of interest are limitless.

The nursing home industry has lobbied to restore this discredited oversight model for decades. It has found a willing and eager partner in CDPH to undermine enforcement of critical quality standards.

CDPH reports it has been using this approach during the pandemic. Is it working?

No, it is contributing to the shocking death toll in California nursing homes from COVID-19.

Almost all California nursing homes with deadly outbreaks received a clean bill of health from CDPH during targeted infection control surveys that were conducted just before or during their outbreaks. Those getting clean surveys include Magnolia Rehabilitation & Nursing Center in Riverside, which was evacuated on April 8 due to a massive outbreak, and Golden Cross Health Care in Pasadena, which was evacuated on June 11 after CDPH suspended its license.

Directing surveyors to collaborate with nursing homes and not to cite them for evident infection control violations while the coronavirus raged through California nursing homes is yet another dark chapter in CDPH’s long history of capitulating to the nursing home industry.

These collaborative inspections are previews of what will occur if California permanently turns its inspectors into partners of the state’s many unscrupulous nursing home operators.

Who should be training and teaching nursing home staff about care standards?

Nursing home operators. The nursing home industry is a $175 billion a year industry that employs tens of thousands of health professionals and infection preventionists. Operators who cannot train their staff to wash their hands properly, to develop and implement care plans to prevent bedsores and dehydration, to provide dignified care to persons who have dementia, and to comply with other quality standards should not be in the nursing home business.  

There is absolutely no need to compromise the integrity and independence of inspectors by forcing them to collaborate with nursing homes they are required to regulate. Wealthy nursing home operators have many other sources they can employ to help them train and teach their staff and to develop compliance plans.

If CDPH has a surplus of nursing home inspectors, it should direct them to investigate its staggering backlog of nursing home complaints instead of turning them into an army of free nursing home consultants. Abused and neglected residents of California nursing homes often die before CDPH investigates complaints about their mistreatment.

Doesn’t the federal government already have a system to provide consultative assistance to nursing homes?

Yes, the Centers for Medicare and Medicaid Services (CMS) funds a nationwide network of Quality Improvement Organizations (QIOs) that serve exactly that purpose.

On June 1, 2020, CMS issued a memorandum to state survey agency directors notifying them that QIOs “have been strategically refocused to assist nursing homes in combating COVID-19 through such efforts as education and training, creating action plans based on infection control problem areas and recommending steps to establish a strong infection control and surveillance program.”

CDPH’s role is to enforce care standards, the QIOs to provide educational support and training. It is critically important that these roles be kept separate.

Didn’t the federal government recently reform its inspection system for nursing homes?

Yes, at a cost of millions of dollars, CMS implemented a comprehensively revised nursing home inspection system in November 2017 after years of research and consultation with stakeholders throughout the nation. CDPH’s plan would jeopardize those reforms and separate it from the inspection standards that guide the rest of the nation.

Why would CDPH propose such a misguided plan and proclaim success in protecting nursing home residents at a time when so many residents are dying from neglect?

Defending the indefensible and ignoring resident suffering in nursing homes is nothing new for CDPH, which has long been in the grip of the nursing home industry. It protects operators, not residents.

CDPH already has authority to conduct monitoring visits in nursing homes as often as it deems necessary. It does not need to “Adopt” skilled nursing facilities to enforce nursing home standards. What is needed is for it to adopt a genuine commitment to stop the epidemic levels of elder abuse that are occurring in California nursing homes and to protect the lives of residents during the pandemic.