INDIANAPOLIS — Over half of Indiana’s nursing homes haven’t received a recertification survey in the last 18 months, including 48 facilities with a history of poor care.

Indiana’s percentage of homes without a recertification survey, 58%, is higher than the national average of 51%. The surprise inspections, called surveys, identify hazards to elder care and play an important role in maintaining standards of care.

But in March 2020, the Centers for Medicare & Medicaid Services (CMS), which regulates nursing homes on a federal level, suspended recertification surveys in favor of infection control, hoping to prepare long-term care facilities for the onslaught of COVID-19.

Donna Emschwiller, the Health Facility Administrator at Christian Care Retirement Community in Bluffton, said that the “intense” process of a typical pre-COVID recertification survey involves a couple of surveyors who split up and cover different parts of the facility.

“It’s not a big secret because you can get the (rubric) online,” Emschwiller said. “It’s basically kind of a flowchart of questions and what they’re looking for… but I think from a facility perspective, it’s a really good tool to help you prepare.”

In contrast, the infection control surveys could last just half a day and came on top of other COVID-19 responsibilities: daily case reporting to state and federal regulators, daily updates to residents and their representatives, sharing education materials with staffers and logging every COVID-19 test.

“I think a lot of facilities were saying, ‘Okay, this is getting crazy.’ Every time they came they wanted the same stuff we gave them last week or the week before,” Emschwiller said. “It’s kind of a crazy amount of paperwork and reporting going on and then you kind of just stop for a few hours and answer their questions.”

The Indiana State Department of Health reported 36 cases and 16 deaths at Christian Care, most confined to a four-week period in the fall. Between Oct. 15 and Dec. 21, the state reported seven infection control surveys with zero citations.

Two other inspections, sparked by a complaint, resulted in the facility’s two infection control citations in mid-November: failure to screen every staffer and failure to isolate a resident re-admitted after a hospital stay.

But while Christian Care’s five-star rating puts it “much above average” in comparison to its peers, many other low-quality facilities continued to operate without the close oversight they had before the pandemic.

States nominate their worst facilities for additional scrutiny and fines through the Special Focus Facilities (SFF) Program. The CMS program conducts inspections twice as often, or every six months, and facilities can face fines or be locked out of payment programs for noncompliance.

None of Indiana’s three SFFs showed improvement in the latest CMS March release and all received their most recent recertification survey before the pandemic closed Indiana facilities in March. CMS dictates that SFFs should be inspected twice as frequently as regular facilities but COVID-19 interrupted that process.

States conduct surveys on behalf of CMS but the health department didn’t immediately respond to questions. CMS directed states to focus their attention on SFFs and SFF candidates as nursing homes reopened in a June 2020 memo.

CMS reports that most homes improve within 18-24 months but about 10% “tend to be” terminated from federal reimbursement programs – such as Medicare and Medicaid. However, due to pandemic disruptions, no facilities were involuntarily terminated in 2020, according to CMS.

“SFF candidates will remain candidates until they are either selected as an SFF or until their health inspection ratings improve enough to come off the SFF candidate list,” CMS said in a statement. “Currently, the average time for graduation is 18.4 months.”

Of Indiana’s 15 facilities that qualify as candidates, 10 haven’t had recertification surveys in the last 18 months. Those 15 facilities have qualified as candidates between a maximum of 23 months and a minimum of 3 months, for an average of 14 months.

This article was made available through Hoosier State Press Association.