A federal report suggests Iowa has one of the nation’s worst ratios of nursing home inspectors to care facilities, and that the state’s use of private contractors to inspect homes is extraordinarily costly to taxpayers.
The report, published earlier this year by the majority staff of the U.S. Senate Special Committee on Aging, highlights some of the issues Iowa regulators have acknowledged with regard to nursing home oversight.
One of the Iowa homes that recently caught the attention of regulators is the Pine Acres Rehabilitation and Care Center in West Des Moines. This past July, state officials visited the home to conduct an inspection, but not before the home had racked up 13 complaints — the oldest of which dated back 109 days, to March 3.
Over the next several weeks, an additional 12 complaints were filed against the home, and a second inspection took place. Eventually, all of the 25 complaints were substantiated by inspectors and Pine Acres was cited for 62 regulatory violations – some of which pertained to neglect that allegedly resulted in the amputation of a resident’s leg.
State and federal records show the timeliness of Iowa’s response to complaints has been an issue for years, predating the outbreak of COVID-19 in early 2020, and then growing worse. In some cases, Iowans have died or suffered serious injuries in care facilities where complaints were pending, having not yet been investigated by the state.
Data from the Iowa Department of Inspections, Appeals and Licensing, which handles complaints against nursing homes, shows the agency has made progress catching up on complaints, in part by paying outside contractors to handle some of the inspections.
However, the Senate staff report, based largely on fiscal year 2022 data, found that Iowa ranks 49th in the nation in terms of its ratio of inspectors to care facilities, and that the use of contractors is expensive and risky.
“Inspection delays endanger nursing home residents,” the Senate staff report states. “A growing number of states have turned to inspectors employed by private companies to bridge gaps — costly contractual arrangements worth millions of dollars that should be subject to additional scrutiny from federal regulators, watchdogs and the press.”
When asked about the report, the Iowa Department of Inspections, Appeals and Licensing said it employs 46 long-term care inspectors and “is in the top eight states in the country” with regard to inspectors’ positions that are filled and not left vacant. The agency acknowledged that it contracts with others, on behalf of the federal government, to complete inspections, adding that it has worked closely with the Centers for Medicare and Medicaid Services, as well as the U.S. Senate Special Committee on Aging, on ways to ensure resident safety in long-term care facilities.
John Hale, a consultant who advocates for Iowa seniors, said the federal report “should be of great concern” to Iowans with family members in nursing homes.
“An analysis of the data shows that the Department is significantly understaffed, deals with the under-staffing by contracting out inspection functions to private companies, and ends up paying more to get less,” Hale said. “The legislature’s oversight committees should be — but aren’t — routinely meeting with the Department of Inspections, Appeals and Licensing and other state agencies to ensure that they are giving taxpayers their money’s worth. Their failure to do so is appalling.”
Among the report’s specific findings:
— Few inspectors: In 2022, Iowa had 46 state inspectors overseeing 414 nursing homes. Some states that have a comparable number of homes had twice that many inspectors on staff. Michigan, for example, had 93 inspectors for 433 homes, and North Carolina had 96 inspectors for 424 homes.
— Higher workload: Only one state, South Carolina, had a worse ratio of inspectors per nursing home. For every inspector Iowa had on staff, it had nine care facilities to oversee. By comparison, Kansas and Nebraska each had 5.7 facilities per inspector, Missouri had 2.7, Minnesota had 4.5, and Illinois had 2.2.
— Unfilled positions: The number of vacant positions for Iowa nursing home inspectors has increased over time. In 2002, there were no such vacancies. In 2022, 9% of the positions were vacant.
— Cost to taxpayers: Iowa has incurred significant expense hiring contractors to handle inspections in place of state employees. The pay range for a registered-nurse inspector working for the state of Iowa is $66,600 to $93,800. But Iowa has paid a private company, CertiSurv, $33,300 per inspection for each facility with 96 to 174 beds. In addition, the company charged the state $40,950 for a single inspection of any nursing homes with 175 or more beds.
— Quality of work: There are only a few private companies qualified to handle care facility inspections, and several states have reported problems with the quality of the contractors’ work. Iowa, however, has taken the opposite view and, according to Senate investigators, state officials have “praised the brevity and conciseness” of the published inspection reports produced by contractors, “even instructing their own employee surveyors to emulate the writing style.”
— Conflicts of interest: Some of the companies that states have contracted to handle nursing home inspections have pre-existing contracts to provide consulting services for the nursing homes themselves – raising questions about conflicts of interest and the diligence of the hired contractors. Iowa officials told Senate investigators “there is no mechanism to track consulting services provided by contractors,” according to the report.
State Sen. Claire Celsi, a Des Moines Democrat, said Monday the findings in the federal report may provide an answer as to why Larry Johnson, the director of the Iowa Department of Inspections, Appeals and Licensing, has not answered some of her questions.
“This totally solves the mystery of the silence from Larry Johnson, who is completely stonewalling me every time I ask why the inspections are so far behind and why, basically, we aren’t having more inspections,” she said. “The mystery is solved: We simply don’t have enough people.”
In April, the Iowa Capital Dispatch reported that while the state had made significant headway in clearing up its backlog of uninvestigated complaints, the number of complaints had been increasing. At that time, there were 48 uninvestigated complaints that were at least 90 days old — a dramatic reduction from 2022, when two dozen complaints had languished more than a year without being investigated.
One of the delayed investigations pertained to Connie Roundy, who lived at Rose Vista Home in Woodbine in January 2020, when her granddaughter complained to the state about issues at the home. The complaint wasn’t investigated by the state until March 2021, six months after Roundy died.
Celsi said legislators can try to address some aspects of the problem, but it could take years for Republican lawmakers to be persuaded the issue needs to be addressed and reach a consensus as to what should be done.
“We should make it mandatory that we have X-number of inspectors for the number of nursing homes we have, absolutely,” she said. “But I have a feeling that nursing homes are not on the governor’s priority list.”
Celsi said that during the upcoming 2024 legislative session, “the public will probably see a change in the way Democrats talk about this issue in the Legislature and that will put some pressure on Gov. Reynolds to do something.”
Dean Lerner, who served as director of the inspections department under Democratic Gov. Chet Culver, said he’s not surprised by the report’s findings with regard to Iowa’s oversight of care facilities.
“This information tells the whole story of the Reynolds’ administration’s attitude toward the health, safety and welfare of our most vulnerable seniors,” he said. “It’s an abomination.”
Gov. Kim Reynolds’ office did not respond to a request for comment.
This article was originally published by the Iowa Capital Dispatch on Nov. 21, 2023. Clark Kauffman is deputy editor of the Dispatch.
