New federal data show that hundreds of Pennsylvania nursing homes had been operating for more than 16 months without full in-person inspections as the state shifted focus to infection control inspections throughout the COVID pandemic.

The report found that 344 of Pennsylvania’s 687 nursing homes hadn’t undergone a full inspection during the period.

Maggi Barton, a Department of Health spokeswoman, said that while there was a pause on nursing home inspections in the spring of 2020, they have since resumed.

"First, it is worth noting that annual inspections were not occurring between March 4, 2020 and June 1, 2020, because of the COVID-19 pandemic," she said. "The Department of Health continued to ensure the safety of Pennsylvania’s health care facilities during this time by conducting virtual inspections and in-person inspections if necessary. Additionally, during this time, we continued to intake and triage complaints according to the federal guidelines from CMS in reference to inspections of facilities during COVID-19, Barton said.

Through Sept. 10, 393 standard surveys had been completed this year, she said. That's more than inspectors completed in all of 2020 when 291 standard surveys were completed. But in 2020, there were also 3,052 complaint-driven inspections and 2,131 COVID-inspired surveys completed, she said.

The U.S. Department of Health and Human Services Office of Inspector General released a report in late July detailing how states failed to address inspection backlogs — vigorous in-person oversight visits commonly called “surveys” by regulators. The federal overseer found 71% of nursing homes nationwide lingered more than 16 months without an annual survey.

Zach Shamberg, president and CEO of the Pennsylvania Health Care Association said that nursing homes are “one of the most regulated industries” and that facilities are subjected to more than 20 different types of surveys by inspectors.

“These surveys help to create transparency and oversight on the care provided to tens of thousands of vulnerable residents,” Shamberg said. “Throughout the past 18 months, and even at the height of the COVID-19 pandemic, surveys — including those for infection control — continued. Today, as COVID-19 cases rise again in surrounding communities, nursing home providers have been successful in keeping case counts down in their facilities — a reflection of the precautions taken to maintain the health and safety of residents."

In addition, the industry has also seen a variety of important quality measures impacting nursing home residents’ lives and well-being — falls, pressure ulcers, depression, urinary tract infections — have improved or remained stable despite the challenges facing nursing homes, he said.

“Nursing home providers are, however, combatting a dire workforce shortage. Access to care is now being limited, and new admissions are being put on hold due to lack of available workers. This should be very concerning for Pennsylvania families who are in need of care for their loved ones,” Shamberg said.

Pennsylvania compares favorably to other states in terms of the percentage of nursing homes that had full inspections. Only New Hampshire, Illinois, Florida, Nebraska, Arkansas and New Mexico had a greater percentage of their nursing homes inspected during the period.

However, as a state with more nursing homes than most, only six states had more nursing homes operating without having a full survey than Pennsylvania: Texas, Missouri, New York, Ohio and California.

In April, a CNHI reporting project found found 51 percent of the nation’s nursing homes had gone without inspections for at least 18 months, a wider timeframe than the July report that accounted for state delays, which predate the pandemic. Since that time, the list of facilities overdue for inspections has grown.

“Comprehensive nursing home inspections — standard surveys — are CMS’s main tool to ensure that nursing homes meet the minimum standards necessary for the safety and wellbeing of residents,” the report said. “Yet, due to the COVID-19 pandemic, states have conducted substantially fewer of these standard surveys, which help to identify and address deficiencies.”

During a typical year, the Centers for Medicare and Medicaid Services (CMS) requires states conduct surveys at least every 15 months to meet federal requirements and maintain Medicare/Medicaid certifications. The intense, multi-day surveys often uncover an assortment of deficiencies in care and require more of operators than other oversight.

In March 2020, CMS suspended recertification surveys and pivoted to infection control surveys, designed to prepare nursing homes for the onslaught of COVID-19 cases. Nursing homes care for some of the most medically vulnerable people in communal spaces, making such facilities the most prone to infectious diseases like COVID-19.

As detailed in CNHI’s report, these surveys catch more problems than the infection control surveys, which can last as little as a half hour.

CMS authorized states to resume the thorough inspections in August 2020, so long as they had the resources necessary to do so. As the report demonstrates, few states managed to catch up on inspection backlogs.

As of June 2020, 8% of nursing homes had gone at least 16 months without a standard survey. Within a year, that backlog ballooned to 71% of nursing homes nationwide, according to the OIG report.

The report’s authors recommend that CMS give states guidance for prioritizing survey backlogs as well as timeframes to complete those inspections, which CMS told CNHI it was doing in March. However, as the report outlines, the problem grew worse since CNHI’s reporting this spring.

“We encourage CMS to take the steps described above to implement this recommendation and help States provide needed oversight of nursing homes,” the report concluded.

In its July 2021 report, the Pennsylvania Department of Health notes that nursing home surveyors conducted 466 inspections — including 289 complaint investigations — of 329 separate nursing homes. Of these inspections, 30 were COVID-19-specific investigations. There were five new sanctions finalized against nursing care facilities in the past month resulting in a total of $40,150 in fines.

“Throughout the COVID-19 response, the department has continued to investigate any complaint made to the department to ensure residents receive the best quality of care,” Acting Secretary of Health Alison Beam said. “We encourage staff, residents and visitors, if you see something, please say something by contacting the department.”

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