Idaho nursing homes haven’t had full inspections in years. How did this happen?

On Dec. 13, 2019, staffers from the Idaho Department of Health and Welfare visited a nursing home, Cascadia of Boise, to conduct an inspection. The resulting report indicated that they found serious problems: call light response times of up to two hours; wrong medications provided to a resident, including lithium and morphine, and a failure to tell guardians about the mistake; and no shower provided to a resident for 20 days.

The facility has not had a full inspection in the nearly four years since.

Health and Welfare surveyors have returned to follow up on the 2019 inspection and complaints filed against the facility in significantly shorter reports, and they’ve conducted fire safety evaluations. In response to the inspection report, Cascadia officials in 2019 said response times have gotten better, the man who received the wrong medication had left, and the resident who didn’t get a shower for weeks “has received showers per his preference and has voiced satisfaction with his shower schedule.” The nursing home promised to make sure advocates were notified about medication errors and residents got the personal care they needed.

But without frequent, comprehensive inspections, the full scope of issues in a facility remains unclear. Cascadia of Boise is one of many nursing home facilities in Idaho that have not had the federally mandated, timely comprehensive inspections.

Other states have struggled with nursing home inspections, especially during the COVID-19 pandemic, but Idaho’s situation is particularly dire, according to a May U.S. Senate Special Committee on Aging report that found the state Department of Health and Welfare had the third highest rate of inspector vacancies in the country. More than 70% of inspector positions were vacant in Idaho at the time of the report, behind only Kentucky and Alabama, leaving just five inspectors to cover the state.

A review of inspection reports publicly available on the Health and Welfare website showed that at many facilities, inspections are still backlogged. Experts say that long delays between inspections, especially at troubled nursing homes, can mean that elderly people are stuck in poor conditions and that ratings for facilities are inaccurate.

“If these facilities do not have a set of eyes going in to make sure things are being done correctly, then these poor people are vulnerable,” said Sallie Schwartzkopf, who was a nursing home surveyor for Health and Welfare from 2019 to 2021. “It’s pretty serious.”

How inspections impact nursing homes, residents

Schwartzkopf, a licensed clinical social worker, had experience taking care of elderly people in her family and through volunteer work. “I wanted to be an advocate for them,” she told the Idaho Statesman. When she was inspecting facilities, it felt like she was making a difference, she said.

Charlene Harrington, an emeritus professor at the University of California, San Francisco, who has researched nursing homes for over 40 years, told the Statesman that without inspections, “there’s no protection.”

The function of inspections is to ensure nursing homes meet federal and state standards, which they must do to receive Medicaid and Medicare funds, Harrington said. The federal government pays state agencies to conduct the inspections.

Facilities are supposed to be surveyed every nine to 15 months, with a statewide average of 12 months, said Toby Edelman, an attorney with the Center for Medicare Advocacy. Those guidelines are set by the 1987 Nursing Home Reform Act. States also complete complaint surveys, which are “more limited in scope” and don’t satisfy the inspection timeline requirements, she told the Statesman. Every inspection team needs a registered nurse for a comprehensive survey, she said.

Robert Vander Merwe, director of the Idaho Health Care Association, which represents nursing homes, told the Statesman he doesn’t think inspections make a big difference to residents but that they impact nursing homes. A facility with a bad rating from an inspection four years ago might be stuck with that score on the Medicare website where people can search nursing homes, even if it’s improved, he said, and a facility might also have new problems that go undetected.

IDHW says its salaries can’t compete with private sector

When Schwartzopf was hired, Health and Welfare had a backlog of inspections and only employed about half of the surveyors it needed, she said. But by January 2020, the department had caught up. Then the pandemic hit.

Retirement age surveyors left, she said. For a while, the inspectors worked remotely, but eventually they resumed inspections, focusing on facilities with the most COVID-19 cases. They were overwhelmed and worried for their safety.

The federal government suspended full surveys in March 2020, Licensing and Certification Administrator Laura Stute told the Statesman in an email. The Centers for Medicare and Medicaid Services resumed the comprehensive surveys in November 2021 but gave no deadline for states to conduct their next comprehensive inspections of nursing homes. Instead, CMS told states it would reinstate the 15-month deadline after they complete the first inspection. Half of the nursing homes in Idaho still haven’t had a comprehensive inspection since 2020, Stute said.

Surveyors complained constantly about the pay, Schwartzkopf said, which seemed to be the main reason for the staff shortage. “It would be aggravating because Idaho has a surplus of money,” she said. “They have the money to pay a decent wage for surveyors or any state position, but they choose not to.” The state had a $100 million surplus at the end of fiscal year 2023, which ended June 30. Last fiscal year, the surplus was $1.4 billion.

Health and Welfare told the Committee on Aging that the salaries for inspectors aren’t competitive because registered nurses start at about $30 an hour with the state, but can earn more than twice that in the private sector. Federal funding has been stagnant, the Idaho agency reported, with no additional money since 2015. Health and Welfare was able to convince the Idaho Legislature to add $3 an hour to inspector pay in 2017, it said, but that increase did not help it to compete during the pandemic. Inspectors received a $2.33 per hour raise this year, Stute said.

This past legislative session, Gov. Brad Little proposed a state employee compensation plan that would have hiked nurse and health care salaries by an average of 14%, said spokesperson Madison Hardy in an email to the Statesman, but the Legislature rejected it.

Twelve inspectors have quit or retired in the last three years, according to personnel information the agency provided in response to a public records request from the Statesman. Health and Welfare currently has eight inspectors, spokesperson Greg Stahl told the Statesman in an email, about half the number necessary.

Cascadia is one of the companies attracting state nursing home inspectors to their jobs. Two registered nurses left positions as Health and Welfare surveyors to work in Cascadia facilities, earning over $20 more per hour, according to undated written testimony submitted to the legislature’s Change in Employee Compensation Committee by Lynne Given, a technical records specialist at the agency.

Cascadia was ‘problem’ facility, former inspector says

On the Medicare web page for Cascadia of Boise, the nursing home’s name has a yellow warning triangle next to it. Hover over the triangle and a text box pops up: “This facility is not rated due to a history of serious quality issues,” it says. “This nursing home is subject to more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid as part of the Special Focus Facility (SFF) program.”

A Special Focus Facility is a nursing home with more severe and long-standing issues than other facilities, according to the Centers for Medicare and Medicaid Services. “If you currently reside in an SFF nursing home, please know that this home is being closely monitored and will be inspected twice as often as other nursing homes,” the federal website promises.

Facilities that don’t improve can lose Medicare and Medicaid funding, something that Cascadia of Boise was threatened with previously when a September 2021 survey, in response to complaints, found the facility put residents at risk of medical complications.

Schwartzkopf said that nursing home was “one of our problem facilities” when she was at Health and Welfare. Cascadia nursing homes didn’t have enough staff in general, she said. Three other Idaho facilities owned by Cascadia Healthcare are candidates for the Special Focus Facility program. Clearwater Health and Rehabilitation of Cascadia, located in Orofino, improved and left the program. No other chain in Idaho has as many nursing homes on these lists.

Of those, only Clearwater — evaluated in February 2022 — received a comprehensive inspection within anywhere close to the last 15 months, the federally mandated time frame. Two of the facilities were inspected in 2021. One, Caldwell Care of Cascadia, hasn’t had a full inspection since Oct. 18, 2019. The Medicare website warns that it “has been cited for abuse.”

In December 2022, state inspectors investigated Caldwell Care after a resident who was supposed to receive CPR did not because a manager told a nurse not to perform CPR until she could check the woman’s code status, according to a state report. The woman died. The nursing home’s own policy said it would notify Health and Welfare of abuse and neglect allegations within two hours, but in this case, officials waited almost a day to do so, the report said.

The facility received a federal fine of $114,455, according to Medicare records. It promised to educate staff about code and abuse reporting policy, the state report said. After the incident, the nurse left and the manager was removed from management.

Steve LaForte, director of corporate affairs for Cascadia, didn’t respond to requests for an interview from the Statesman.

Idaho tries to recruit inspectors

The federal government now allows Health and Welfare to recruit dietitians and licensed practical nurses to act as inspectors, the Idaho agency told the Statesman. And the department said it’s giving inspectors $3,000 sign-on and retention bonuses that come with a promise to stay for a year.

In addition, since at least 2018, the department has used contract surveyors to supplement state employees. The money comes from vacant staff positions. Health and Welfare pays them about $81 to $97 per hour — more than twice the hourly rate for state employees, according to the current contract that Health and Welfare provided to the U.S. Senate committee.

For Schwartzkopf, it didn’t seem like there was much hope. She left her state surveyor job to be a rehabilitation unit case manager at a hospital. The pay was similar, but the job would allow her to do the work with seniors she wanted, she told the Statesman.

“I could see also that the issues with the survey program were not getting better,” she said.