The Baltimore City fire marshal fined an assisted-living facility $2,500 for bolting five separate doors shut last week, after a medical call brought inspectors in for an unscheduled inspection.
"They abated the problem," Baltimore City Fire Department spokesperson Ian Brennan says of the facility on the 3600 block of White Avenue. "They removed the bolts. I believe that the state and city health departments are investigating."
The state inspection just might be a too-rare thing.
Just days before WBAL-TV broke the story (contrary to what WBAL reported, it was not a fire), a state auditor reported that the Office of Health Care Quality (OHCQ), whose job is to inspect every one of the state's medical facilities every year, actually inspects less than half of the assisted-living facilities.
"Specifically, for fiscal year 2012, OHCQ had not performed inspections for 757 of the 1,364 (55 percent) licensed assisted living facilities nor inspected 143 of the 197 (73 percent) facilities for the developmentally disabled," the audit report, covering the period from August 2010 to March 2013, says.
The inspection shortcomings have been ongoing for a decade, the auditors noted.
In its response to the audit, OHCQ officials said they're doing the best they can with the limited resources they have. "As previously stated, the OHCQ is unable to meet the inspection requirements due to a shortage of personnel. In the 2013 Annual Report and Staffing Analysis, the OHCQ estimated that 67.9 more surveyors would be needed in order to fulfill these requirements. To address these concerns with limited resources, in January 2013, the OHCQ implemented a strategic planning process that included an evidence-based review of our survey protocols in the context of the statutory and regulatory requirements. One of our broad organizational goals is regulatory efficiency, that is, how to best use our limited resources to fulfill our mission. We are continually striving to protect the health and safety of vulnerable populations while efficiently and effectively utilizing our limited resources."
Boiled down, the OHCQ is looking for ways to inspect the facilities that they believe need inspections more often, and let the ones that have proven themselves alone, says Patrick Dooley, the chief of staff and assistant secretary for Regulatory Affairs for the Department of Health and Mental Hygiene, which oversees the Office of Health Care Quality. "They're looking more at targeted surveys . . . rather than a one-size-fits-all approach," Dooley says.
This, too, has been the mantra of the office since at least 2005. "Over six years regulating assisted living programs, we have learned that the 'one size fits all' approach is not realistic and does not work," the authors of a 2005 program evaluation wrote.
As baby boomers age, develop dementia, and require 24-hour supervision, the state's assisted-living market has been growing. With monthly fees averaging over $3,000 and much of it paid by Medicaid, it's a potentially lucrative small-business opportunity for landlords. Concerns about its relatively unregulated state led to reforms in 2006 after an evaluation by outside experts under Robert Ehrlich's gubernatorial administration.
"The state's assisted living program has grown rapidly since its implementation in 1996 and the office of Health Care Quality has identified an emerging pattern of serious quality of care issues," the 2005 report to the Senate Finance and the House Health and Government Operations committees said. "As a result, the Department of Health and Mental Hygiene (DHMH) and members of the Legislature have expressed concerns about the direction the state should take in regulating assisted living facilities."
The inspections back then resulted in seven or eight facilities being shut down each year. OHCQ inspectors found patients with bedsores, patients that wandered off and froze to death, patients locked in a boiler room for "behavioral problems," assisted-living managers forging checks to themselves and claiming to be doctors and nurses when they weren't, and seminars for hopeful landlords "who were told that government funding of health care was the next way to 'get rich quick.'"
Some of the reforms implemented by then were the requirement of a two-week "assisted living manager training course" plus 20 hours of continuing education every two years. The state mandated that delegating nurses complete a 16-hour course and that registered nurses—rather than less-trained licensed practical nurses—perform resident assessments.
The panel made seven recommendations for further improvement, including "evaluating workload and priorities to ensure that OHCQ staff are deployed most efficiently."
But the economy crashed shortly after that, so implementation has been a challenge. The new inspection regime, which includes "targeted surveys that meet all statutory and regulatory requirements," were just implemented in January, according to the agency's response to the audit.
The White Avenue facility, called Royal Heart Assisted Living, is owned by Ngozi Wilkens. A person who answered the phone at the facility refused to talk to City Paper, hanging up twice on a reporter.
Property records show she bought the place in 2010 for $289,000 from a home-flipping LLC that had bought it a year earlier from Fannie Mae for $57,000. Wilkens then filed to establish it as a 12-bed assisted-living facility. In a September 2011 memo the city health department supported the effort. "The facility is a large, three-story single detached home with seven bedrooms," the memo to City Council says. "On the first floor there are three bedrooms, one single, [one] double and one with the capacity for three single beds . . ." Four bedrooms on the second floor share a single bathroom and could accommodate seven more patients, the memo says.
Still listed in state tax records as Wilkens' principle residence (though other court records show her residing in a Rosedale apartment complex), the house appears to be in good shape, with an inviting wrap-around front porch punctuated by a fire-code-required stand pipe. On July 1 a woman is on the porch with a cigarette in her mouth and a very young boy on her knee. Asked if she is Ms. Wilkens, she replies, "Who's that?"
The woman, who declines to give her name because "I don't want to be on the news," says she is visiting her uncle at the facility, and that the owner personally showed her inspection reports saying there is nothing wrong at the facility. "The TV station should not have the right to report lies," the woman says.
The woman says her uncle has dementia and has been here about a year, and that the care at Royal Heart is much improved from his previous residence. In three months there, he got bed sores, she says: No bed sores at Royal Heart.
It is unclear why the doors were bolted shut. People with dementia sometimes wander off, but there are devices that can hold doors shut until a keypad is punched and that allow the door to open automatically in the event of a fire or other emergency.
"My mother-in-law is in a facility like that and they have copious protections that do not involve bolting the door shut," says Brennan, the fire department spokesman. "They are putting the people they care for in great danger. There is no room for sympathy."