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"State skipping clinic checkups"

Original source:

Silicon Valley/San Jose Business Journal

By Laura Cutland
Updated: 7:00 p.m. ET March 19, 2006

Albert Quintero, the state watchdog for hundreds of health facilities in the San Jose area, says it's been as long as 15 years since some of them have been inspected.

He freely admits that this violates state regulations, but he says he's powerless to comply with all of the inspections his office is expected to do.

The problem, the San Jose district manager for the Department of Health Services' licensing and certification division says, is that he hasn't been able to hire the nurses he needs.

These coveted workers are in short supply in Silicon Valley, Mr. Quintero says, and they're increasingly being lured away by hospitals offering sky high salaries.
"We don't have the staff to send," he says. "It's hard to recruit people down here."

This means some inspections are being delayed for years and hundreds of complaints are not being responded to for months or more at the government agency responsible for making sure hospitals, nursing homes, community clinics and homes for developmentally disabled are meeting basic quality standards such as cleanliness and adequate staffing levels.

Among the valley facilities getting little oversight are ambulatory surgical centers which, in some cases, haven't seen a DHS surveyor since 1991. Primary care clinics, which often treat the poor and uninsured in San Jose, haven't seen agency officials at their doorstep in seven to eight years in many cases. And numerous hospices, which tend to the dying, haven't been inspected by DHS since 1998. The problem is not limited to San Jose.

DHS officials acknowledge that inspection and complaint delays are common throughout the state. And they blame it on inadequate resources. "Anything that's been more than five years [since we inspected] -- we recognize that as a problem," says Scott Vivona, chief of the Bay Area field operations branch of DHS. "It's a sad reflection that we don't have the staff."

That may be true, say consumer groups and organizations that follow the health care industry, but it's no excuse.

"These are our most frail and vulnerable populations," says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. "There's no excuse for not sending someone for eight years." It wasn't always this way, says Mr. Quintero.

Four to five years ago, his office was staffed with more than 20 people, not 14, and Mr. Quintero says it could do a reasonable job of meeting many of its guidelines, which include certifying and inspecting over 400 facilities in the San Jose area. His office is also supposed to respond to complaints, which average more than 1,000 a year.

But when housing prices in Silicon Valley starting going through the roof and a state law kicked in last year requiring hospitals to bump up their nurse staffing levels, the agency wasn't been able to compete with the private sector, he says.
DHS pays nurses up to $67,548 a year but most local hospitals start RNs at $75,000, usually with a hefty signing bonus.

Mr. Vivona says the steep decline in DHS staff levels began in 2001, when the Davis administration imposed a hiring freeze that prevented the division from filling positions. More recently, it has been exacerbated by the raising of some health care salaries at other state departments, such as mental health and corrections.

Inspection delays that date back to the early 1990s are due to "priorities, staff availability, and restrictions of federal funding," according to a DHS spokeswoman.

The result is a lot of judgment calls and triaging of responsibilities, Mr. Vivona says. Most district offices are placing a top priority on inspecting nursing homes, intermediate care facilities and home health agencies. And they try to get to all complaints involving an immediate threat to a patient within 24 hours. The rest they get to when they can.

Mr. Vivona adds that there are other entities out there that provide some level of oversight for health care facilities. In the case of hospitals, for instance, the Joint Commission on Accreditation of Healthcare Organizations -- a nonprofit that inspects hospitals on a voluntary basis -- performs inspections every three years while some health care clinics have to meet guidelines set by other agencies or funders.

Still, that's troubling to Ms. McGinnis, among others.

DHS has a long history of neglecting its duties, she says, particularly when it comes to nursing homes. She points to several government reports released this year by the California Legislative Analyst's Office and the U.S. Government Accountability Office which found weaknesses in how the government oversees homes that care for elderly. And she notes that state legislators, aware of some of these issues, recently ordered an audit of the DHS' licensing and certification division.

"The department doesn't want to enforce the law," Ms. McGinnis says. "The will isn't there."

Maribeth Shannon, a director at the California Healthcare Foundation, an Oakland-based nonprofit that studies health care issues, agrees that long delays have dogged the agency for years. That's a problem, she says, because the public has an expectation that the people placed in health care facilities are being watched over.

"We have regulations in California for a reason," Ms. Shannon says. "Peoples' lives are at stake."

Others note that while the lack of inspections is a concern, even worse for patients is the poor follow-through on complaints.

Investigating allegations months after an incident can be futile, says Mary Jann, director of developmental programs at the California Association of Health Facilities, an industry group based in Sacramento. "Things change and the people aren't there."

DHS leaders say matters may improve this summer when the state budget is up for approval. The licensing and certification division is slated to get money to create 141 new positions, 96 of which will be for surveyors.

Missing their checkups

The San Jose office of the California Department of Health Services' licensing and certification division has a spotty record in fulfilling its duties as the overseer of hundreds of health care facilities in the area.

Among the organizations it's supposed to inspect for things like patient rights, quality of care, cleanliness and adequate staffing levels are hospitals, nursing homes, community clinics and homes for developmentally disabled. The office is also supposed to respond to a variety of complaints regarding these facilities, which can range from allegations of assault to the serving of cold soup.

But the district manager for the San Jose area says lack of staff has prevented the office from carrying out some of those requirements. His staff of 14 is responsible for more than 400 facilities and the fielding of more than 1,000 complaints every year.

Here's a closer look at the state regulations and how the San Jose office measures up:


  1. Hospitals: No inspections in one and half years.
    Requirement: License and certification inspection every three years. DHS officials note that they are using inspections performed by the Joint Commission on Accreditation of Healthcare Organizations in conjunction with the Institute for Medical Quality (part of the California Medical Association) to fulfill its requirement. The former organization inspects about 80 percent of the nation's hospitals every three years on a voluntary basis.
  2. Nursing Homes: Meeting requirement.
    Requirement: License inspection every two years. Certification every 12 months, not to exceed 15 months.
  3. Intermediate Care Facilities (which includes homes for developmentally disabled): Meeting requirement.
    Requirement: License inspection every two years. Certification every 12 months with two month extension possible.
  4. Home Health Agencies (organizations that care for the sick in their own homes): Meeting requirement.
    Requirement: License and certification inspection every three years.
  5. Primary Care Clinics: Some haven't been inspected in 7-8 years.
    Requirement: License inspection every six years.
  6. Ambulatory Surgical Centers: Some haven't been inspected in 15 years.
    Requirement: License inspection every six years.
  7. Hospices: Averaging an inspection every eight years.
    Requirement: No state requirement but federal requirement every six years.


DHS categorizes complaints according to severity with top priority given to allegations of immediate threat to a patient, such as an assault, while lower priority assignments could include complaints of cold food or loud noise.

  1. Top priority: Meeting requirement.
    Requirement: Respond within 24 hours.
  2. Lower Priority: Response time averaging 45-60 days.
    Requirement: Respond within 10 days.