Purpose

To determine whether the Department of Health's monitoring and inspection of nursing homes is sufficient to determine if nursing homes perform comprehensive inspections, testing, and maintenance of resident care-related medical equipment. The audit covered the period January 1, 2015 through October 27, 2017.

Background

The Department of Health (Department) oversees nursing homes in New York State through its Division of Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities Surveillance (Division). The Division also acts as an agent for the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS), in monitoring quality of care in nursing homes. The Division is responsible for ensuring nursing homes are in compliance with federal and State regulations designed to optimize the health, safety, and quality of life for the approximately 117,000 people living in nursing homes in the State.

The Division assesses and certifies nursing home compliance through unannounced, on-site inspections, commonly referred to as surveys, including:

• Certification surveys, which include both Standard Health (quality of care) and Life Safety Code (LSC) (fire and safety) inspections;

• Complaint surveys, which investigate complaints and incidents reported by nursing homes or third parties; and

• Follow-up surveys, which monitor nursing homes’ progress in correcting previously noted deficiencies.

The LSC component of the Certification survey covers inspection of all essential mechanical, electrical, and resident care equipment to ensure their safe operating condition in accordance with Section 415.29(b) of Title 10 of the New York Codes, Rules and Regulations.

As established in Part 483 of Title 42 of the Code of Federal Regulations, as of July 2016, nursing homes that participate in federal reimbursement programs are required to comply with 2012 National Fire Protection Association (NFPA) safety codes and standards. With the adoption of NFPA regulations, among other actions, nursing homes are now required to:

• Establish policies and protocols regarding the testing intervals of patient care-related electrical equipment; develop a program for electrical equipment maintenance considering manufacturer service manuals; and retain records of tests and repairs.

• Inspect generators weekly, and exercise the generators under load for 30 minutes 12 times a year and for 4 continuous hours once every 36 months.

• Maintain readily available written records of generator maintenance and testing.

CMS’s Basic Health Facility Surveyor Training and State Operations Manual provide guidance to surveyors for conducting NFPA compliance surveys. For this purpose, the Department created a Long Term Care Equipment Inventory Form (Inventory Form) to provide surveyors with a list of the different types of equipment commonly used at nursing homes. The Department requires its surveyors to review service records and manufacturer requirements for a random sample of resident care-related equipment pieces, based on the size of the facility’s resident population (i.e., number of beds) and for at least one piece of non-resident care-related equipment. This requirement implemented by the Division was modeled after the Department’s Division of Hospitals and Diagnostic and Treatment Centers’ methodology and is accepted by CMS.

The Division has four regions with seven offices throughout the State that carry out survey functions. The regions are Capital District, Central New York, Western (with offices in Buffalo and Rochester), and the Metropolitan Area Regional Office (MARO) (with offices in New York City, Central Islip and New Rochelle). Of the 625 nursing home facilities currently active in New York State, over half are located in the MARO area. Between January 1, 2015 and December 31, 2017, the Division completed 2,223 surveys, including 1,648 Certification surveys.

Key Findings

• The Department completes its Certification surveys in a timely manner and reports deficient practices to the public, as required. However, we identified gaps in the Division’s procedures that weaken its ability to effectively monitor nursing homes’ equipment inspection, testing, and maintenance programs. For example, a list of the types of equipment in use at a facility (Inventory Form) for use by the surveyors is not always comprehensive. We found that the Form does not include some types of resident care equipment, such as heart monitors, electrocardiograms, and dialysis machines that are in use at some facilities.

• The Department’s equipment sample sizes meet federal requirements. However, the samples are very small relative to the number of equipment items in the facilities. For example, one 120-bed facility we visited had approximately 500 pieces of resident care-related medical equipment, of which only 4 would need to be reviewed. We question whether the Department’s standard sample sizes based on a facility’s number of beds are optimal to identify equipment deficiencies, such as at facilities with histories of poor survey results.

• We visited a judgmental sample of 36 facilities and observed the condition of 532 durable medical equipment items and found the items to be in good condition overall. However, the facilities did not maintain some equipment according to manufacturer recommendations or lacked records of their maintenance for other items. Additionally, maintenance personnel at 13 facilities could not provide documentation that the four-continuous-hour generator tests were conducted every 36 months as required, and 4 of the 13 facilities were not aware that this test was required.

Key Recommendations

• Improve oversight of nursing home resident care medical equipment by periodically updating the Inventory Form to add types of medical equipment known to be in use at nursing home facilities, such as the durable medical equipment items identified in this report.

• Formally evaluate whether equipment sample sizes should be based on factors such as the size of a facility’s medical equipment inventory and a facility’s prior survey history.

• Remind facilities of the requirements for preventive maintenance of medical equipment and generator tests and record keeping of these activities.

Other Related Audit/Report of Interest

Department of Health: Nursing Home Surveillance (2015-S-26)