California Department of Public Health Gives Cover to Some of California’s Most Dangerous Nursing Homes During Deadly Outbreaks

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Are the federally ordered COVID-19 infection control surveys of nursing homes a fraud?

One can certainly make a case that they are in California based on data and inspection reports released by the federal Centers for Medicare and Medicaid Services (CMS) on June 4, 2020.

On March 20, 2020, CMS ordered state survey agencies to suspend almost all types of nursing home surveys and directed them to temporarily institute a new system of “targeted” infection control surveys aimed at “ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.”

The new CMS data and inspection reports are the public’s first chance to see what inspectors found during approximately 5,700 onsite surveys that were conducted between March 4 and April 29 in the nation’s nursing homes.

The California results are beyond shocking. While the data indicates that California surveyors conducted over 1,700 onsite surveys in nursing homes during that period, not one of the targeted infection control surveys appears to have led to a nursing facility being cited for an infection control violation.

CANHR’s review of the released inspection reports found that over 150 California nursing homes were cited for one or more deficiencies during this period. However, none of the cited deficiencies in these reports were issued during a targeted infection control survey. Rather, most of the cited deficiencies were from recertification surveys and complaint investigations that were conducted before CMS suspended these visits on March 20.

Only 16 of the released survey reports involve California nursing homes that were cited for violating F-880, the CMS tag associated with its infection control standard for nursing homes. All of the cited violations in these reports were based on regular recertification surveys or complaint investigations that took place before March 20 – not the new targeted surveys. Inspectors classified all of these violations as non-harmful to residents, consistent with the GAO’s recent report finding that inspectors almost never find poor infection control practices in nursing homes to be harmful.

Accordingly, based on the CMS data, it appears that over 1,500 California nursing homes had onsite visits during this period where no deficiencies were issued.

How did some of California’s most dangerous nursing homes get infection control clearances during deadly outbreaks?

One of the targeted infection control surveys took place in early April at Magnolia Rehabilitation & Nursing Center in Riverside days before all of its residents were evacuated on April 8 due to a massive outbreak and an extreme staffing crisis. Yet a CDPH COVID-19 infection control survey report dated April 7 found Magnolia fit for duty regarding infection control.

Many other California nursing homes with deadly outbreaks also got CDPH’s seal of approval during targeted infection control surveys. For example, CDPH reports it found no infection control deficiencies during targeted inspections at Cedar Mountain Post Acute in Yucaipa, Stoney Point Healthcare Center in Chatsworth, Grand Park Convalescent Hospital in Los Angeles, Windsor Vallejo Nursing & Rehabilitation Center, Stollwood Convalescent Hospital in Woodland, Dycora Transitional Health – Fresno, Kingston Healthcare Center in Bakersfield, The Rehabilitation Center of Santa Monica, Brighton Care Center in Pasadena, Country Villa Sheraton Nursing and Rehab Center in North Hills, Sea Cliff Healthcare Center in Huntington Beach, Las Colinas Post Acute in Ontario,  Turlock Nursing Rehabilitation Center,  Parkwest Healthcare Center in Reseda,  Santa Anita Convalescent Hospital in Temple City, Hollywood Premier Healthcare Center in Los Angeles, Four Seasons Healthcare & Wellness Center in North Hollywood, Astoria Nursing and Rehab Center in Sylmar and the South Pasadena Care Center.

Why would California nursing home inspectors uniformly fail to cite infection control violations during targeted infection control surveys intended to protect residents from the coronavirus?

Because they were ordered not to cite nursing facilities. On May 22, 2020, the Assistant Deputy Director of the Center for Health Care Quality at CDPH told CANHR that he had verbally directed California surveyors not to issue deficiencies during the first round of infection control surveys. Inspectors were instead told to “collaborate” with nursing homes during this period.

More than 2,000 residents have suffered and died alone in nursing homes throughout California while CDPH performed toothless inspections ­– courtesy call visits – at some of the most dangerous nursing homes in the state. Who is going to hold CDPH leaders accountable for tying their own hands and abrogating their role at a time when California nursing home residents needed them most?