By Brenda Gazzar, Los Angeles Daily News, February 20 2021
A Los Angeles County watchdog is calling for the Public Health Department to create a nursing home crisis and response plan in light of major safety problems that surfaced during the coronavirus pandemic.
Two Pasadena nursing home evacuations last year revealed “serious operational deficiencies” in these facilities that threatened the safety of residents and gaps in state and county procedures for triggering an “effective, timely and coordinated response,” according to the second interim nursing home report by the Los Angeles County Office of Inspector General.
The Inspector General’s report can be found here
The evacuations at Golden Cross Health Care in June and Foothill Heights Care Center in October also revealed issues with the efficacy of the county’s Health Facilities Inspection Division’s oversight and enforcement actions, as well as coordination between HFID and local partner agencies.
“Although each evacuation was precipitated by different underlying circumstances, both appear to have been preceded by several weeks of unsuccessful efforts to rectify potentially life-threatening issues,” stated the interim report, which was released Tuesday evening.
When asked to respond to the report, the county’s Department of Public Health listed a series of actions it took that officials said have reduced COVID-19 cases, hospitalizations and deaths in nursing homes. Regarding the two facilities that had to be evacuated, the agency suggested that it acted appropriately within given protocols and parameters.
The serious operational deficiencies at these two nursing homes “led to the emergency transfer of residents from those facilities,” the agency said in a statement.
It also said that its HFID arm, which is charged with licensing and certification of health facilities in the county, “intervened to protect residents and acted according to the protocols and guidance” of the California Department of Public Health and the federal Centers for Medicare and Medicaid Services.
The Los Angeles County Board of Supervisors appointed Inspector General Max Huntsman, a former prosecutor, in June to conduct an exhaustive review of the county’s capacity to regulate nursing homes.
More than 3,735 nursing home residents and at least 126 staff members have died from COVID-19 in Los Angeles County since the start of the coronavirus pandemic, according to online state data. Nursing home deaths make up about 20 percent of all COVID-related deaths in the county.
L.A. County Supervisor Kathryn Barger, whose district includes Pasadena, hopes the report can be used “as a road map to strengthen the care of those in skilled nursing” and other congregate-care facilities, said spokeswoman Michelle Vega, who noted Wednesday that the supervisor had yet to read the report.
Golden Cross evacuation
Before Golden Cross’ license was suspended in June due to ongoing quality-of-care issues, the home’s “management deficiencies” exacerbated a COVID-19 outbreak and became a catalyst for a facilitywide crisis, the report said.
The county’s HFID determined in late March and in late April that the facility was in compliance with infection control and prevention requirements to limit COVID-19 spread. Weeks later, the Pasadena Public Health Department and the California Department of Public Health documented the facility’s noncompliance with cohorting and other infection prevention and control protocols.
HFID conducted several site visits and investigations, identified deficiencies, made several immediate jeopardy findings, mobilized significant resources and appointed a temporary facility manager. However, “quality of care did not improve and substandard conditions festered for more than one month before an evacuation was initiated,” the report found.
By then, 71 residents and 32 staff members had contracted COVID-19 and 16 residents had died. Officials from the city of Pasadena, ombuds and a California Medical Assistance Team (CAL-MAT), which is coordinated from the state’s Emergency Medical Services Authority, voiced their belief that the facility should have been evacuated sooner.
CAL-MAT said it had witnessed several staff members wearing improper PPE while working in COVID-positive zones, reusing disposable PPE for several consecutive days and moving from zone to zone without taking off PPE or adequately cleaning their hands, the report stated.
The team also observed that “several residents lost a significant amount of weight due to lack of adequate food and water,” prompting the Pasadena Fire Department to provide food and water to residents, to deliver PPE to staff and to install fencing around the facility to control the movement of residents and staff.
Pasadena and ombuds officials reported they were rarely included in conversations with the county and state about whether an evacuation was needed, despite their first-hand knowledge, according to the report.
A Golden Cross representative could not be reached. The facility is currently closed and its owners are locked in a legal battle with the state to keep its license and transfer management of the facility to another company.
Foothill Heights evacuation
Residents at another Pasadena facility, Foothill Heights Care Center, were evacuated in October following multiple complaints — starting in August — of excessively high temperatures inside the building and residents’ rooms.
HFID issued an immediate jeopardy finding, citing the home’s failure to “maintain air conditioning and ventilating systems in normal operating conditions to provide a comfortable temperature.” However, the immediate jeopardy determination was lifted after the facility’s correction plan noted that staff was checking room temperatures hourly — and that an electrician had installed five electrical outlets in five residents’ rooms for five additional portable air conditioning units.
During October, after residents’ rooms reached 92 degrees and even higher in the hallway, the city of Pasadena’s then-fire chief — who said the HFID surveyor was unable to document a need to evacuate the facility — took his concerns to the deputy director of CDPH’s Center for Health Care Quality, the report said. Within four hours, all residents were relocated in a coordinated emergency response led by the Pasadena Fire Department.
HFID “cited the facility’s efforts to remediate deficiencies, the risks associated with resident transfers and the notion that older residents like warmer temperatures in response to why it did not pursue more serious action sooner,” the Inspector General’s report stated.
A manager at Foothill Heights, which has since been repopulated, did not return calls this week for comment.
The county public health department said in its statement that HFID’s contract with the state obliges it “to seek guidance and obtain approvals” from the state’s public health department to enact emergency transfers from nursing homes. HFID does not have the authority to initiate an evacuation in the event of a facility-wide crisis but can recommend evacuations and other emergency responses to the state, the report noted.
Evacuations are considered serious undertakings with inherent risks to frail, older residents, the report added. While research supports keeping residents in place whenever possible, quick action may be necessary to protect residents’ health and safety when a facility fails to adequately address deficiencies.
In Los Angeles County’s contract with the California Department of Public Health, CDPH retains significant substantive and operational authority over the county’s HFID while L.A. County’s public health department retains administrative control. This arrangement “appears to impede both communication” between HFID, the rest of the county’s public health department and the state’s public health department and effective nursing home oversight and regulation, the report stated.
When asked to comment on the report, CDPH said in a statement that protecting the state’s most vulnerable, including nursing home residents, has been a priority before and since the pandemic. It also listed a series of actions it has taken during the pandemic, including providing these facilities PPE and implementing “a proactive six-point approach for nursing homes to promote quality care and minimize infections.”
The report “cannot begin to capture the frustration we felt at the local level in dealing with this disconnect and the lack of timely response to the situations at Golden Cross and Foothill Heights,” Pasadena Assistant City Manager Nicholas George Rodriguez said in an emailed statement.
“The City, even with its own Health Department, does not have legal enforcement authority over these facilities and, in spite of the obvious deficiencies, was unable to convince those with that authority to step in and to properly take charge in a timely manner,” Rodriguez said. “Interim steps were not properly managed, and the City had to push hard for evacuation when it should have been clear that this was the only possible solution.”
The city of Pasadena handled the physical evacuation of the residents even though the county “has far more resources,” he said, adding that the county was unable to get a strike team together to handle the evacuation.
Meanwhile, the California Department of Public Health was “not on the ground, was not local or present and (was) giving direction remotely from Sacramento,” he said.
CDPH, for its part, said it “issued a temporary suspension order against (Golden Cross Health Care) and oversaw an orderly relocation of residents.”
The inspector general’s report recommended that “a crisis mitigation team” be designated within the county’s Public Health Department to “coordinate closely” with HFID with appropriate expertise in geriatric medicine, nursing home care and administration, residents’ rights and disabilities access, infection control and prevention and environmental health and safety “to provide support to HFID.”
The county Public Health Department would provide “clear thresholds” for when the team should be deployed to nursing homes that fail to remedy immediate jeopardy findings and, if needed, formulate and implement crisis response plans.
The county’s Auditor-Controller’s Office, whose final findings on HFID’s abilities were also included in the inspector general’s report, further found that HFID management did not demonstrate that it adequately manages or tracks the various stages of all of its current and backlogged investigations. The auditor-controller also found that HFID also does not adequately track enforcement actions to ensure that deficiencies are resolved in a timely manner.
The county public health department said both the IG report and the auditor-controller’s findings “made clear that Public Health had continuous oversight of the situations” and “was working collaboratively with both state and local officials … to protect residents.”
It also noted that HFID nurses took “a range of steps … to intervene and improve conditions in both facilities,” including on-site probes, daily monitoring of COVID-positive residents and staff and assigning a temporary state-appointed manager.
While the county health department voiced “some areas of concern with characterizations or assessments made” in the reports, it “agrees with the generalized recommendations” made by the offices of the inspector general and auditor-controller.
County public health officials said they would clarify at a later date issues related to the contract with the state, HFID’s recordkeeping as well as current and future workload issues.
Any proposed change that the county makes in response to the inspector general’s audit would need to be approved by the state public health agency, CDPH said. That’s because the county is contracted with them to provide these services to the state agency on behalf of the federal Centers for Medicare and Medicaid Services.
Moving the needle
Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform, said the watchdog report sounded “pretty damning of the work that HFID has been doing for years and has been doing throughout the pandemic.” The report, he said, also highlights the “dysfunctional relationship or contract that it has with the state.”
“It confirms what we’ve known for years — that L.A. (County’s) HFID has not been up to the job of overseeing and monitoring nursing homes in L.A. and consequently nursing home care in L.A. has been … among the worst nursing home care in the country — consistently.”
Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said he thought the report was “a forward looking, thoughtful, analysis of a complex issue.”
“I’m encouraged by the breadth and specificity of the recommendations,” the geriatrician said by email. “If fully implemented, it can move the needle on the quality of care.”
Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, which represents more than 900 nursing homes in the state, said the watchdog report did not address “the dramatic difference in licensing fees in L.A. County” compared to the rest of the state.
“Of particular concern are reports of low morale among surveyors who state they are overworked and inadequately trained because that will impact the survey process. Yet provider licensing fees in L.A. County are 35 percent higher than the rest of the state,” she said via email. “There’s a lot for the state to digest regarding this point and other recommendations.”
The inspector general’s final report on improving oversight and accountability for nursing homes is scheduled to be released on May 21, according to his office.
The county health department said it will also offer a “formal, in-depth” response to the Board of Supervisors regarding the auditor-controller’s findings within 60 days.
Staff writer Bradley Bermont contributed to this report.