Alicia Knothe

Alicia Knothe moved her mother to The Terrace of St. Cloud assisted living facility in St. Cloud, Fla., after having a bad experience with her mother's care at a facility in Maryland in 2012. A new owner took over the Maryland facility a few months later. (Stephen M. Dowell, Baltimore Sun / July 18, 2014)

The Maryland health agency responsible for overseeing medical facilities, including the group home where a disabled foster child died this month, is moving to reduce the number of facilities it inspects across the state — even as it acknowledges that thousands of complaints and inspections have not been properly handled.

The Office of Health Care Quality says the policy change stems in part from a long-standing, and growing, problem: a shortage of inspectors. The agency proposes to cede some oversight to accrediting organizations while focusing its inspections on facilities with a history of serious problems.

But advocates say that could limit oversight of medical facilities and state contractors such as LifeLine, which ran the Laurel-area home where 10-year-old Damaud Martin died July 2. LifeLine has had financial and regulatory problems in recent years, and the company's founder was imprisoned in 2013 for arson.

Kate Ricks, chair of Voices for Quality Care, a Maryland and Washington-based health advocacy group, said the policy change "could be disastrous" because well-run facilities can go downhill quickly after a change in ownership or management.

"It is just insane that we're the wealthiest state in the nation and we cannot afford to put enough staff to monitor the facilities that take care of the people most in need," she said.

The health care quality office is the primary agency responsible for overseeing more than 14,000 facilities that handle some of Maryland's most vulnerable residents. It has the power to investigate complaints, levy fines and revoke licenses of nursing homes, hospitals, assisted-living facilities and similar operations.

In annual reports and audits, the office, which is part of the health department, has acknowledged that it does not meet the requirements of some state or federal laws. For example, the office has failed to conduct annual inspections of thousands of facilities. Over a period of years, thousands of complaints have gone uninvestigated. And delays in responding to complaints are frequent.

Officials are shifting to a "risk-based" approach, in which the agency would stop trying to make annual inspections of certain kinds of facilities if they are believed to be well-run and concentrate on those with a history of problems.

"Our goal here is to protect the public," said Maryland Health Secretary Dr. Joshua M. Sharfstein. "Our goal is not necessarily to meet a pre-specified, minimum frequency of inspections to check a box. And so working within the law and regulations we have, we want to be as effective and efficient as possible."

A state audit released last month found that the office had not performed annual inspections of 55 percent of Maryland's licensed assisted-living facilities or inspected 72 percent of facilities for the developmentally disabled in fiscal year 2012 despite a state mandate. Only 8 percent of the 3,606 complaints at facilities for the developmentally disabled had been investigated on-site in fiscal year 2013, according to a special report mandated by the General Assembly in response to inspection issues.

Audits going back more than a decade have found similar shortcomings. The agency acknowledges that for at least a decade it has not met federal mandates calling for serious nursing home complaints to be investigated within 10 days, and that it usually takes more than a month to respond.

Nancy Grimm, director of the office from 2009 to 2013, said that it has never been sufficiently staffed but that she and other employees tried their best.

"You don't have much choice except to focus on those facilities that have histories of problems, those facilities that seem to have had the most complaints over a period of time and the most severe of the complaints that come in," said Grimm, now a private attorney. "Even I would lie awake nights worried that we might be missing something, and we probably were to some degree."

Sharfstein said he wants to essentially formalize that approach for some providers.

Sharfstein and Patricia Nay, the office's director, said the staffing shortage was not the sole reason behind the shift. Accreditation organizations, they said, are staffed with health experts and offer a more comprehensive look at the quality of care. They also are looking for ways to make the office more efficient, such as using a new computer system to track inspections. They started making the changes last year and say that it will take another year or two to put the rest in place.

"What I tell my surveyors is, we all have to sleep at night and not be afraid of the providers," Nay said.

She and Sharfstein said that relying on accrediting organizations will not work for all types of health facilities; for some, such as nursing homes, federal law requires state inspections. But the new approach could be used at facilities for mental health care or assisted living, they said.

Such changes could require legislation, Sharfstein said.

The office would still investigate complaints, and if problems arise, "ultimately we hold their license," Nay said.

The office is currently allotted 118 surveyor positions, though on average about 10 have been vacant since the beginning of last year. The agency estimated that it needed 107 more surveyor positions last fiscal year. But this year, officials say, the changes already put into place have cut the estimated shortage to 68 positions.