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.
A daughter's nightmare
Alicia Knothe found she had to be persistent to get inspectors to the Catonsville assisted-living facility where her mother was living in 2012.
The carpet in Etta Wendt's room reeked of urine and feces, her daughter said. The octogenarian Alzheimer's patient had difficulty walking to the dining hall, but staff members refused to take meals to her room. The facility failed to get her mother's prescription for pain medication filled, and a request from an outside doctor to perform blood work fell through the cracks, Knothe said.
By June 11, 2012, Knothe had had enough and put her complaints in a letter to state regulators and managers at Paradise Assisted Living.
Regulators did not start an investigation into Knothe's allegations for four weeks. Meanwhile, she continued to document problems, including a complaint that the staff did not respond for up to an hour when Wendt pressed a call button for assistance. She also said her mother had fallen several times.
"The conditions were horrendous," Knothe said.
According to guidelines, the state health care quality agency is required to investigate within two days cases of "immediate jeopardy," in which a person is at risk for serious harm or death. Among the triggers for such a review are a "nonfunctioning call system" and repeated falls.
When state inspectors visited the facility over a period of two days, they found that "resident health and safety is endangered by a reliance on a pendant emergency notification system that is essentially nonfunctional."
A patient with dementia had wandered out several days before the inspectors came, records of the visit show. Staff members did not know he was gone until police returned him.
Inspectors found more: an "overwhelming" smell of urine in the carpet of one room; patients who didn't get their daily medications. Part of the ceiling was missing in one patient's room, and water dripped from an exposed pipe into a trash can.
The health quality agency fined the facility $10,000. A new owner took over a few months later.
Current owner Pradip Ghosh said the former operators did not tell him of Knothe's complaint or the fine. He said he found problems when he assumed ownership and has fixed them. The facility's director was replaced shortly after the change in ownership, he said.
"We made sure that all of those issues were taken care of fully before we took over," Ghosh said.
Former Paradise officials either could not be reached for comment or did not respond to requests for comment.
Knothe said she doesn't know why it took weeks for the state to investigate, but thinks the wait would have been longer if not for her persistence.
"I just don't know if it was the constant phone calls: 'You've got to get somebody out there, you've got to get someone out there,'" she said, adding that the $10,000 fine was "way too light."
Knothe, who lives in the Orlando area, moved her mother to a new facility near her home shortly before Paradise was sold and is much happier with her care.
A heavy burden
The Office of Health Care Quality's staffing shortage goes back to at least 1999, when a U.S. Government Accountability Office report spotlighted Maryland and three other states to show why nursing homes needed more federal oversight. Then, the agency took four months to investigate the complaint of a resident found with dried blood and sores covering his body.
The shortage has grown as the agency's responsibilities have expanded. It now oversees 14,452 facilities and home health care organizations, up from about 8,000 in 2006.
Those facilities and providers include ambulatory surgical centers, home health agencies, endoscopic centers, hospice care, birthing centers, medical care in correctional facilities, physical therapy centers, substance abuse treatment facilities and forensic labs. Abortion facilities have recently been added.
The office's budget in fiscal year 2014 was $18.3 million, a fraction of the Maryland Department of Health and Mental Hygiene's overall budget of $10.4 billion, much of which is mandated spending on Medicaid. The office's number of positions is approved annually by the legislature; it gained two positions last year.
Grimm and William Dorrill, her former deputy, who also left the agency to form the law practice Grimm and Dorrill, said surveyors suffered from working long hours and the worry that critical problems could be falling through the cracks.
"People are frustrated, they know they can't do their job correctly, and you're so far behind all the time it burns people out," Dorrill said.
Advocates say they have lobbied the legislature to significantly increase the agency's budget for years and have gotten nowhere. They say the agency has good staff members who are hamstrung.
Ricks, of Voices for Quality Care, said most Marylanders are unaware that the agency plays a critical role because many residents do not have relatives to advocate on their behalf.
"The people you're trying to speak for don't write letters to the editor, they don't write to their legislator," Ricks said. "You have a totally hidden constituency here."
Two staff members who were in leadership roles before leaving the agency within the past year said turnover has been a problem.
As more facilities were added to the agency's responsibilities, experienced employees have left, under pressure from new leadership or because of the increasing burdens. In the past year or so, more than a dozen key officials left posts in information technology, and licensing and inspection programs in substance abuse, mental health, assisted living and developmental disabilities.
"We relied heavily on judgment," said one staff member who wants to pursue future state government work and did not wish to be identified. "And when you replace [them] with people who don't know what they're doing, or don't replace people, it slows things down. ... It's worrisome."
Richard Mollot, director of the New York-based Long Term Care Community Coalition, said other states, too, have problems inspecting medical facilities each year. His advocacy group is pushing for more federal oversight. He said he did not know of any other states looking to use accreditation in lieu of regular inspections.
"It's unfortunate that the states are not held more accountable for this," he said. "The system is just not in any way ... doing what it's supposed to."
Problems at LifeLine
At LifeLine, state inspectors found "serious deficiencies" in staffing and care at its adult facility in Owings Mills beginning in 2009, and subsequent reviews cited the company for inadequate care. Three adult residents died in 2010 and 2011, and the state revoked the company's license to care for adults.
LifeLine was allowed to continue to care for children at a set of Laurel-area apartments. Inspectors found no significant concerns in the children's program until this year, when the state found evidence of inadequate care and began moving to revoke its license. The last child was removed from LifeLine's home the day after Damaud died.
Regulators continue to investigate the death and whether LifeLine's care was adequate. Officials have cautioned that it is too early to draw conclusions.
But the state did not receive timely information about LifeLine's problems, a recent investigation by The Baltimore Sun found.
The Sun informed the state of at least 10 allegations of abuse and neglect recorded in Anne Arundel County police and fire reports in 2013 and 2014. LifeLine also failed to notify the state about its bankruptcy filing in 2012, a $1.2 million IRS tax lien filed last year and a $45,000 lien filed in April by the state.
In 2012, LifeLine did not get a relicensure survey, the mandated annual review in which health inspectors typically interview patients and staff, and examine records related to care. Instead, it got a less thorough examination.
Nancy Pineles, an attorney with the Maryland Disability Law Center, said it is not clear whether regulators would have identified LifeLine's problems sooner had they done a relicensure survey in 2012. But she said the case underscores the importance of the state agency's inspections.
Her group supports accreditation as long as it does not replace regular inspections.
"The problem with moving away from surveying everyone on a regular basis is you don't have data to assess if a provider is performing well," Pineles said. "If you don't have data that's reliable, you can't make a determination whether a survey is required, and we're dealing with vulnerable populations."
Baltimore Sun reporters Meredith Cohn and Doug Donovan contributed to this article.