When the Rehabilitation Center at Hollywood Hills submitted its emergency management plan to county administrators in July, it included details on how the nursing home would maintain clean linen, distribute canned food and ensure that residents had access to hand sanitizers.
It made no mention of how residents would be kept cool if the home lost power.
That was a tragic oversight. On Wednesday, health regulators said, eight residents of the rehabilitation center succumbed to cardiac and respiratory failure after a portable air-cooling system malfunctioned.
The home's failure to foresee the catastrophic consequences of an air conditioning meltdown — and Broward County's failure to insist that the home do so — point to a serious statewide problem. Florida's emergency planning system for long-term care facilities is the government equivalent of a take-home exam: Providers administer the exercise themselves, drill themselves and are expected to honestly report on their shortcomings and correct them.
In its emergency hurricane drill conducted in October 2016, the Hollywood nursing home described its communication and safety and security as good, though it noted that improvement was needed "to manage resources and assets more organized." It said the same thing in a June 2017 hurricane drill, using the same language.
Most long-term care facilities "don't have an emergency management plan that is worth the paper it's written on," said the state's first elder affairs secretary, Bentley Lipscomb. "Because nobody requires them to. They are only required to keep patients barely alive."
Nursing homes are required only to have backup generators to power life-saving equipment such as nursing call buttons and fire alarms. Many homes keep their generators in storage and neglect to maintain them, said Lipscomb, who oversaw the Department of Elder Affairs from 1992 until 1998.
On Saturday, Gov. Rick Scott announced that he was directing two state agencies to implement emergency rules to apply to all 685 nursing homes and 3,109 assisted living facilities in the state to require them to "obtain ample resources, including a generator and the appropriate amount of fuel, to sustain operations and maintain comfortable temperatures for at least 96 hours following a power outage."
The governor ordered the rules to be adopted swiftly and to take effect in 60 days. The Atlantic hurricane season extends until Nov. 30.
Florida's nursing home industry says it supports Scott's emergency rule, but it has concerns about the practicality of implementing it — especially in time for the end of this hurricane season.
To address those concerns, the industry's trade association has called a "Nursing Center Emergency Preparedness Summit" on Friday in Tallahassee.
Among "host of concerns" about the rule's implementation, said Kristen Knapp, spokeswoman for the group, is how the senior homes will pay for the equipment, the timing of the generator requirement, and also what they should do with the fuel required to power the generators. She said that there may be local zoning laws that prohibit homes from hosting the amount of fuel needed to power generators for four days.
The summit will include "long-term care providers, utility companies, generator suppliers, emergency management personnel, regulators, government officials and other emergency planning partners."
Federal regulators have said in guidance to nursing homes that they are not required to install generators. "CMS (Centers for Medicare and Medicaid Services) does not specify what type of alternate type of energy source or emergency and standby power system a facility chooses," the agency wrote, creating considerable confusion as to how CMS, and the state governments which will enforce the CMS rule, intend to interpret it.
Under state law and administrative rules, nursing homes are required to submit a "comprehensive emergency management plan" to their county government each year.
In Broward County, once the plan is filed with the emergency management division, administrators conduct a "paper review" to ensure that all portions of the plan meet requirements, said Miguel Ascarrunz, the county's director of emergency management.
"We look at the documentation of the plans and ensure that those components are in compliance," he said. "If they're not in compliance, we send them a letter saying, 'Your plan is not in compliance.' "
But the emergency management division does not send inspectors to verify what facilities report. Hazard drills, for example, are conducted on their own. The county reviews the self-assessments of their performance.
Local fire agencies conduct their own reviews of the emergency plan's fire safety procedures, Ascarrunz said.
State health care regulators merely verify that a plan has been submitted.
"All nursing home facilities and assisted living facilities are required to have an emergency management plan," said Mallory McManus, a spokeswoman for the state Agency for Health Care Administration, which regulates hospitals, nursing homes and assisted living facilities. "This plan is required to be submitted and kept on hand by county emergency management officials. As part of the licensure process, AHCA confirms that the facility's emergency plan has been submitted to local officials," she added.
The Hollywood Hills nursing home, in what appeared to be self-conducted evaluations of its hazard drills, gave itself consistent ratings of "good" and "excellent" in 2016 and 2017. The grades were among the few good marks the facility has received: Federal health regulators gave the rehab center a health inspection rating of "much below average," and an overall rating — including such things as staffing and fire safety — as "below average" this year.
In a 2016 exercise simulating a Category 5 hurricane warning for the Fort Lauderdale area, the nursing home said its staffing performance was "excellent," along with patient and utility management.
Brian Lee, who was Florida's long-term care ombudsman from 2003 to 2011, said the state's emergency management system for nursing homes and assisted living facilities suffers from "lax oversight and no accountability."
"These plans are little more than rubber stamped by county offices and emergency management officers, and AHCA only verifies their existence," Lee said.
Miami Herald staff writer Mary Ellen Klas contributed to this report.