Nursing home inspectors focus on infections as Trump rolls back regulations

With the coronavirus outbreak growing, Iowa’s nursing home inspectors are focusing on infections that threaten the 55,000 elderly and disabled Iowans now living in long-term care facilities.

The focus on infection control has been suggested by the same federal agency that has been working for months to ease Obama-era nursing home regulations intended to minimize life-threatening infections.

The coronavirus is known to pose a particularly serious threat to the elderly and to people with underlying health conditions. The Centers for Medicare and Medicaid Services — a federal agency that delegates nursing home inspections to state agencies like Iowa’s Department of Inspections and Appeals — has suggested that inspectors focus their attention on infection-control issues.

DIA has adopted CMS’ guidelines and says its inspections will give first priority to so-called “immediate jeopardy complaints” that allege a situation in which an Iowa home is causing, or is likely to cause, serious injury or death.

The inspectors will then zero in on complaints alleging infection-control concerns. The agency is placing specific emphasis on homes and hospitals that in the past three years have been cited for infection-control deficiencies at the immediate-jeopardy level.

“We are committed to protecting the well-being of Iowans who rely on the care they receive at our state’s network of health care facilities,” said DIA Director Larry Johnson, Jr. He said the agency will “take any steps necessary to bolster the preparedness of facilities to combat the spread of COVID-19 and any other infectious disease.”

DIA is also following CMS guidelines by recommending, but not ordering, restrictions on nursing home visits, with exceptions for “compassionate care, such as end-of-life situations,” said department spokeswoman Stefanie Bond.

A recent analysis by Kaiser Health News found that at least 9,697 of the nation’s nursing homes, or 63%, had been cited for one or more infection-control deficiencies at some point during the past three years. A USA Today analysis of similar data indicates the rate of infection-control violations in Iowa is roughly 64%.

The effort by CMS to roll back certain infection-control regulations was first reported this week by the New York Times. The newspaper found that last July, before the spread of coronavirus, CMS initiated efforts to roll back a variety of regulations imposed by the Obama administration — one of which would require all nursing homes to employ at least one specialist in preventing infections.

The agency proposed eliminating the requirement to have even a part-time infection specialist on staff. Instead, CMS proposed, homes would be required to ensure that anti-infection specialists spend an unspecified but “sufficient” amount of time at each facility.

The language is similar to that of staffing requirements for nursing homes in many states, Iowa included. In place of specific employee-to-staff ratios, the homes are required to employ a “sufficient” number of caregivers. That terminology has long been the focus of criticism from advocates who say it’s too vague to be enforced.

In 2018, the attorneys general in 17 states, including Iowa Attorney General Tom Miller, wrote to CMS and called the effort to undo the Obama-era nursing home rules a threat to “the mental and physical security of some of the most vulnerable residents of our states.”

They letter cited a report from CMS’ own Office of Inspector General, which estimated 22 percent of Medicare beneficiaries had experienced an adverse event — including infections, pressure sores and medication-induced bleeding — while in a nursing home. Nearly 70 percent of these adverse events could have been avoided, the OIG said, and more than half resulted in harm serious enough to require hospital care.

CMS administrator Seema Verma has said the proposed changes are not intended to weaken oversight of nursing homes but to avoid “micromanaging the process.”

The changes, she said, could result in homes opting to impose a “higher level of staffing” than what would otherwise be required. She added, however, that, the federal agency wants to “make sure that our regulations are not so burdensome that they hurt the industry.”

CMS estimates that the proposed rule changes would save the nursing home industry about $640 million a year.

Each year, roughly 380,000 nursing home residents are killed by infections, according to CMS. At one Washington state nursing home, 13 residents died recently after being infected with the coronavirus, and more than one-third of the facility’s 180 employees have contracted the virus.

About 55,000 Iowans live in Iowa’s 800 long-term facilities, which include roughly 400 nursing homes, 360 assisted living centers, and 40 residential care facilities.

In 2016, nursing homes in Iowa were rated as among the worst in the nation, due to  serious, repeat-offense violations that caused actual harm or placed residents in immediate jeopardy. Only six other states — including the two most populous states, Texas and California — were cited for more violations of that kind.

In 2017, the first year of the Trump administration, federal fines against Iowa homes dropped by half, to $2.3 million. While the number of violations that triggered fines had increased slightly, the penalties, on average, were half what they were in 2016.