One in four Missouri nursing homes hasn’t had a standard inspection in two or more years, according to recently updated federal data.
Federal law requires states conduct an unannounced comprehensive inspection for each long-term care facility at least every 15 months to assess compliance with federal health and safety rules.
During those visits, inspectors generally spend several days at each facility reporting on factors including medication management, resident rights and quality of life.
State rules require annual inspections.
Of the 510 nursing homes in Missouri, 126 have not been inspected in at least two years, according to data published by the U.S. Centers for Medicare and Medicaid Services in July.
The nonprofit investigative newsroom ProPublica’s Nursing Home Inspect database combines several CMS data sources to make them more easily searchable across reports.
According to ProPublica’s database, Missouri has among the largest inspection backlogs in the country. The worst backlog is in Kentucky, where 74% of nursing homes have been awaiting inspection for more than two years.
The inspections are run by state agencies but overseen with federal standards.
The state is “really behind,” said Marjorie Moore, executive director of VOYCE St. Louis, an advocacy group for long-term care residents.
Moore said that makes it harder for people to access accurate information about facility quality, and potentially raises the risk the state is overlooking issues.
“When the surveys haven’t been updated in two or three years, there’s a lot of times facilities have changed hands at that point (and) there’s been significant changes in facility quality since COVID,” Moore said.
“Then on top of that, they’re not catching some of the important stuff that they would typically catch,” she later continued.
Nursing home inspections were put on hold during the early days of the COVID-19 pandemic, creating an initial backlog that was compounded by national staffing shortages and increased demand for inspectors to survey for COVID-19 infection control in facilities.
In May, a U.S. Senate committee published a report on the issue called “Uninspected and Neglected” and held a hearing about the “strained nursing home inspection system.”
At the congressional committee hearing, Shelly Williamson, who serves as Missouri’s administrator for the section for long-term care regulation for the Department of Health and Senior Services, testified about the state’s challenges.
COVID-19 meant that “many of our normal survey activities were paused, creating a backlog that is contributing to the difficulties today,” Williamson said. “Infection control surveys were often in nursing homes that were experiencing widespread COVID-19 outbreaks, adding to surveyor stress, illness and burnout.”
Now, years from the initial pause in inspections and the COVID-19 surges in long-term care facilities, a major cause of the delayed inspections is that there has been a significant increase in complaints, Lisa Cox, spokesperson for the Department of Health and Senior Services, said in an email to the Independent.
The number and severity of complaints has risen, Cox said, stretching inspectors thin. Those inspectors are required not only to perform annual reviews of facilities but also to investigate specific complaints.
The number of complaints against long-term care facilities increased around 36% over the past four years, Cox said.
The largest increase was in severe complaints, Cox said, which are defined as complaints that could result in “immediate jeopardy” for residents and require action within 24 hours. Those increased by 125% in those three years, Cox said.
Complaints categorized as “non-immediate jeopardy high complaints,” which allege actual harm and must be investigated within 10 working days, increased by 25%, Cox said.
“With this increase in the number of complaints, the section is not able to investigate all within the required timeframes,” Cox said.
The state is currently meeting the time frame for the most severe complaints, Cox said, and meets the next most severe “between 65%-70%” of the time.
“Because of the increase in the number and severity of complaints, the regulatory functions of (the section for long-term care regulation) have become reactionary to complaints,” Cox said, “rather than proactive in identifying concerns at nursing homes before complaints occur.”
Complaints have risen as staffing numbers within nursing homes declined over the course of the pandemic, Moore said. Pay and benefits for long-term care staff are generally low, she said, and they’re “some of the hardest jobs in health care” — requiring care “a lot of people aren’t willing to do.”
She also said she has also observed large corporations increasingly buying facilities and cutting staff to increase profit. In March, Missouri senior care workers rallied at the state Capitol to make the case for improved conditions, KOMU reported. In their letter to the governor, they wrote that “inspectors aren’t out there to find and correct problems, so the whole system is just cycling downward.”
Nurses in high demand
Workforce challenges have exacerbated delays with inspections, Cox said.
Annual inspections require at least one registered nurse, she said, and many complaints require a nurse too, depending on the allegations.
The agency has needed to cancel annual inspections because of a lack of available qualified nurses, Cox said.
When recertification inspections do happen, Cox said, they often take more time because there has been a trend of increasing number and severity of issues found.
Citations for issues are called deficiencies in nursing home inspections. The average number of deficiencies at recertification surveys increased from 6.5 in fiscal year 2019 to 9.7 in fiscal 2023, Cox said. The severity worsened, too: The number of “actual harm and immediate jeopardy deficiencies” increased by 70% over the same time.
Those severe deficiencies need to be investigated, taking more resources. For instance, the inspectors may need to interview more residents to ensure the review is comprehensive, and the investigation may broaden in scope to determine the extent of the deficiency.
The ProPublica database allows users to search deficiencies in specific nursing homes or geographically. If a home has not had a standard inspection in more than two years, it will have an “inspections delayed” flag at the top of its page.
Vetoed ombudsmen funding
Every state has long-term care ombudsmen, who are staff and volunteers tasked with advocating for long-term care residents. The program has been in place federally since the 1970s.
It’s an arm of oversight separate from state-funded inspectors, but they often work in tandem, said Moore, whose organization operates the ombudsmen program for St. Louis and Northeast Missouri regions.
Sometimes, they may resolve issues before they rise to the level of making a formal complaint to the state and needing a visit, she said.
“A lot of times the ombudsmen are there to help the facility and the resident come to solutions before the state needs to step in,” Moore said.
Other times, the ombudsmen help report issues to the state.
Moore said the ombudsmen often serve as liaisons between nursing home residents and the facilities, looking into complaints such as residents not getting their food on time or not getting enough assistance to go to the bathroom — many issues surround short-staffing, she said.
The ombudsmen have been meeting their goals for visiting each facility at least three times each year, Moore said, but could increase their visits and resources to assist with increasing complaints if they had more staff.
The Legislature approved $2.35 million in the budget to go to the long-term care ombudsmen program in the state, which Moore said would have enabled the regional program she oversees to hire more than 20 new ombudsmen to help advocate for nursing home residents. She said it received no public opposition during the last legislative session.
But Gov. Mike Parson vetoed $2.2 million of that funding, noting a general need to ensure a balanced budget and the “financial stability of Missouri,” and pointing to another funding source to meet those needs.
Moore said due in part to the constraints of the other fund Parson suggested, it is unlikely they receive support from it.