Council to Receive Update on Actions Taken on Report on Improving Oversight at Skilled Nursing Homes

In a special meeting with Supervisor Kathryn Barger, the City Council will discuss an interim report on oversight of skilled nursing facilities.

The report issued by the Office of Inspector General (OIG) questions whether the Los Angeles County agency responsible for oversight of skilled nursing facilities can effectively address crises and protect residents’ health.

The assessment of the county’s Health Facilities Inspection Division (HFID) centered on two emergency evacuations from Pasadena facilities in June and October.

“On June 11, 2020, more than 60 residents were evacuated from Golden Cross Health Care (Golden Cross) in Pasadena after the facility’s license was suspended due to ongoing quality-of-care issues,” the report states. “Fewer than four months later, on October 1, 2020, the OIG responded to Foothill Heights Care Center (Foothill Heights) in Pasadena where more than 30 residents were evacuated due to excessive indoor temperatures. Although each evacuation was precipitated by different underlying circumstances, both appear to have been preceded by several weeks of unsuccessful efforts to rectify potentially life-threatening issues. The evacuations revealed issues with state and local mechanisms for triggering a crisis response,  efficacy of HFID’s oversight and enforcement actions and  coordination and communication between HFID and partner agencies.”

These events “highlight flaws in HFID’s crisis identification and response and resident abuse and neglect investigations,” the report found.

OIG personnel met with city officials, including the city manager, the assistant city manager, the fire and police chiefs,  the city prosecutor, and the director of public health.

The city Health Department reported that in early May 2020, it received reports of staffing shortages at Golden Cross due to a COVID-19 outbreak. According to the report, by May 8, the Health Department had learned that a significant portion of the nursing staff were temporary workers obtained through nursing registries. HFID was immediately made aware of the staffing issues and began to closely monitor conditions at Golden Cross. 

HFID requested assistance from the U.S. Navy to supplement staffing and help implement COVID-19 mitigation protocols. A U.S. Navy team was on-site at Golden Cross from May 8 through May 11. 

HFID conducted site visits from May 12 to May 14 and requested a National Guard team to provide assistance and assess Golden Cross conditions, but the guard did not provide assistance.  

“On May 14, 2020, 11 days after the HAI nurse provided instruction on infection control, the National Guard team assessed the facility but declined the mission the following day reportedly due to the facility’s failure to adequately cohort residents by COVID-19 status,” the report states.

The report also included a final analysis by the county’s auditor-controller identifying “significant operational deficiencies that appear to impede HFID’s ability to fulfill several of its oversight responsibilities”

The complicated interaction between the state public health agency that controls licensing and enforcement and the local public health team responsible for oversight has led to a situation where it is unclear when to declare residents in jeopardy and begin a crisis response, according to the OIG’s analysis.

Research supports keeping elderly, frail residents in place whenever possible, making such a decision fraught to begin with. A number of local, state and federal agencies were made aware of problems at the Golden Cross Health Care facility in Pasadena and spent weeks trying to remedy potentially life-threatening issues before moving to evacuate more than 60 residents on June 11 — after the facility’s state license was suspended.

“By the time the decision was made to evacuate the facility, 71 residents and 32 staff had contracted COVID-19 and 16 residents had died,” the OIG reported.

“Officials from the PPHD (Pasadena Public Health Department), the Pasadena Fire Department, Ombuds and the CAL-MAT (rapid deployment team) expressed the belief that Golden Cross should have been evacuated sooner.”

According to the report, officials from the city’s Health Department, the Ombuds and the Pasadena Fire Department said that they were rarely included in conversations with HFID and CDPH about whether an evacuation was necessary, despite having firsthand knowledge about the conditions based on multiple site visits and close monitoring. 

Officials from both agencies contacted HFID leadership several times throughout late May and early June expressing concerns for the health and safety of residents and requesting updates, to which HFID leadership reportedly responded they were waiting on direction from CDPH, the report states.

One of the most critical breaches of protocol by the facility, flagged in May by a state nurse, was that Golden Cross wasn’t keeping residents with positive cases in an isolated area away from other residents.

Problems in complying with COVID-19-related health orders were exacerbated by staffing shortages created by an outbreak of the virus that led to the facility employing many temporary workers as nurses. At one time, the U.S. Navy was called in to help supplement staffing, the report states.

Nearly a month before the evacuation, the county Health Facilities Inspection Division declared that multiple conditions posed “immediate jeopardy” to residents and called in a state rapid deployment team to help remediate problems.

However, the HFID opted not to evacuate immediately, but to place Golden Cross on a 23-day “termination track,” according to the report. 

The state team subsequently raised additional concerns, pointing to the staff’s failure to medicate residents in accordance with doctors’ orders and noting that several residents had lost weight due to a lack of adequate food and water.

As the problems and complaints piled up, on May 27 the Pasadena Fire Department came up with a plan for evacuation, and a nonprofit social services organization identified an alternative facility within 15 miles. HFID leadership said they were waiting on guidance from state officials.

In addition to issues related to coordinating with the state, the report found, HFID is not well integrated into the county’s Public Health Department. Leadership at DPH wasn’t informed of the issues at Golden Cross until a few days prior to the evacuation, the OIG reported.

In addition to the concerns about reacting to crisis situations, the OIG and related audit also identified a backlog of thousands of complaints awaiting investigation.

As of June 30, 5,407 investigations remained open, nearly half of which have been open for more than three years. A total of 547 were categorized as posing immediate jeopardy.

“The failure to investigate complaints in a timely manner can limit HFID’s ability to … substantiate allegations and prolong situations in which residents may be subjected to unsafe circumstances and neglect,” the report concluded.

The OIG offered 13 recommendations, including designating a crisis mitigation team with clear protocols to trigger an emergency response and a plan to better integrate HFID staff into the Public Health Department.

It also called on DPH leadership to assess the accuracy of concerns raised by HFID staffers about a lack of training and undue pressure to close inspections.

“If true, the issues alleged may impact the county’s ability to oversee SNFs, protect the health and safety of residents and fulfill its contractual obligations with (the California Department of Public Health,” the report stated.

“If reported accounts are untrue, the common perception of multiple HFID staff and supervisors is itself concerning and calls for further evaluation and appropriate intervention.”