by Lucas Thomae and Jane Winik Sartwell
State oversight of nursing homes received a scathing performance audit, released on Wednesday.
The Office of the State Auditor released its audit of the Department of Health and Human Services’ oversight of nursing homes, accusing the department of consistently failing to conduct timely inspections and investigations of nursing homes across the state.
As of December 2023, 425 federally certified nursing homes were operating in North Carolina, with a total of 44,128 beds. The DHHS Division of Health Service Regulation’s role is to routinely inspect those nursing homes and investigate complaints involving them.
According to the auditor’s office, which often conducts performance audits of various state agencies, DHHS often did not complete those inspections and investigations within the state-mandated time frame.
The central findings of the audit are as follows:
- The division did not conduct timely inspections of nursing homes during the period of March 1, 2021, through Dec. 31, 2023.
- The division did not complete investigations of nursing home complaints within the time frame prescribed by state law during the period of Jan. 1, 2019, through Dec. 31, 2023.
- The division did not always verify the correction of nursing home deficiencies identified during inspections of nursing homes during the period of Jan. 1, 2019, through June 30, 2022.
The Office of the State Auditor determined that 68 percent of all inspections were late, and 10 percent of North Carolina nursing homes went more than 20 months without an inspection. For higher-risk nursing homes, DHHS must conduct inspections every six months.
In 67 percent of these inspections, the division exceeded the six-month limit between inspections. During the pandemic, 96 percent of nursing homes went more than 15 months without an inspection.
At nursing homes that went long periods of time without an inspection, state inspectors would eventually report allegations of abuse, failure to treat medical conditions and provide care, distribution of expired medications and complaints of lack of dignity. Residents had their feet dragged under wheelchairs and personal hygiene needs ignored, inspectors said.
Staffing issues and backlogs due to COVID-19 are to blame for routinely late inspections, according to the auditor’s office. DHHS had a 13.3 percent vacancy rate in December 2023, with 14 jobs open. The division’s turnover rate averaged 17.8 percent.
DHHS does not have a comprehensive nursing home response plan to pandemics or other crises, according to the auditor’s office.
DHHS is required to investigate complaints within 60 days. Between January 2019 and December 2023, the division received 17,152 complaints that required investigation — in 39 percent of these cases, the division did not investigate within 60 days.
Uninvestigated complaints mentioned in the audit included avoidable falls, failure to administer medications, inappropriate use of restraint and other instances of abuse and neglect.
The auditor’s office recommends DHHS seek resources from the General Assembly to clear its backlog of overdue inspections and conduct timely investigations of complaints.
The audit also found that DHHS did not consistently verify correction of identified deficiencies at nursing homes across the state. DHHS failed to verify that 37 percent of 612 identified deficiencies were ever corrected.
“Division management did not have formal procedures in place to track the deficiencies and perform a documented, formal review to ensure the verifications occurred and were documented,” the audit reads. “Instead, according to Division management, they performed informal, undocumented reviews.”
DHHS complains that audit lacks context
DHHS issued a response letter signed by Deputy Secretary Mark T. Benton, which is attached to the published audit. In the letter, Benton rejected the audit’s findings on the basis that the time frame included the COVID-19 pandemic and therefore couldn’t be considered a “routine time.”
The response also states that because 96 percent of nursing homes in North Carolina are federally licensed, DHHS considers itself to do regulatory work on behalf of the U.S. Centers for Medicare and Medicaid Services. According to the response, CMS concluded that DHHS met or exceeded all annual performance measures for the same period as the state audit.
However, CMS was not the only federal agency that has reviewed North Carolina DHHS oversight of nursing homes and past results have not always been favorable.
In 2018, the U.S. Department of Health and Human Services issued an audit through its Office of Inspector General that found serious concerns with North Carolina’s nursing home oversight in about 5 percent of cases, though less problematic than the issues the inspector general identified in some other states. North Carolina DHHS also was defensive about the federal findings at that time but ultimately agreed to take corrective action.
Regarding the newly released state audit, North Carolina DHHS agreed with the state auditor’s assessment that the agency is understaffed and would benefit from more funding, and added that the General Assembly has not granted requests for additional staff four years in a row.
Carolina Public Press reached out to DHHS for additional comments and response to the audit, but a department spokesperson deferred back to the original response letter dated Oct. 11.
Also included in the audit is a response to DHHS’ response, in which the auditor’s office accused the department of making “misleading and misguiding statements.” The Office of the State Auditor clarified that it excluded time periods from the audit scope during which DHHS inspection and investigation activity was suspended because of COVID-19.
The auditor’s office also shot down DHHS’ claim that they are only bound to federal guidelines, calling the department “first and foremost an agency of the state of North Carolina” and pointing out that federal requirements instruct health agencies to follow the inspection and investigation timelines of their own states in the case that those requirements are more stringent.
The release of the audit came as a surprise to many people in the world of health care advocacy, including Disability Rights NC public policy director Corye Dunn. She took exception to DHHS’ complaint that the audit shouldn’t have taken place during a time period that included a pandemic.
“I don’t think that we can just set aside all standards anytime there’s a crisis,” Dunn said.
“I think it’s harder than that, and I also think that we can’t use a crisis to explain away the responsibility of the state. There’s always some crisis that you can point to as the thing that is taking up resources or time or causing difficulty in hiring, and North Carolinians deserve the protection of their state government even when times are tough.”
Dunn said she hopes policymakers consider how to better incorporate disaster planning into state functions, including facility oversight.
Carolina Public Press has reported previously on issues with the Division of Health Service Regulation’s oversight of other long-term care facilities, especially adult-care homes, which are distinct from nursing homes and typically house adults of any age with mental health or cognitive conditions.
During the pandemic, Carolina Public Press pointed to evidence that early severe outbreaks of COVID overlapped in several cases with nursing home facilities that had received negative citations on inspections, especially for issues involving cleanliness and biohazards.
During the early months of the pandemic, DHHS refused to release information on the size of outbreaks at individual nursing homes in the state. However, after Carolina Public Press and a coalition of other news organizations filed suit, DHHS relented and began releasing the information on a regular basis.
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