Nursing homes need improved emergency plans. But who will verify them?

A report by the Florida House’s Select Committee on Hurricane Response and Preparedness includes recommendations on how to improve emergency management plans from nursing homes and assisted living facilities. But the recommendations are thin on oversight that would make sure those plans are better verified.
In this Wednesday, Sept. 13, 2017 file photo, a woman is transported from The Rehabilitation Center at Hollywood Hills as patients are evacuated after a loss of air conditioning due to Hurricane Irma in Hollywood. [AP]
In this Wednesday, Sept. 13, 2017 file photo, a woman is transported from The Rehabilitation Center at Hollywood Hills as patients are evacuated after a loss of air conditioning due to Hurricane Irma in Hollywood. [AP]
Published Jan. 22, 2018

Two months before a dozen residents died in sweltering heat at the Rehabilitation Center at Hollywood Hills, the now-shuttered nursing home submitted a plan to county administrators to show the facility could handle crises like a missing resident or a hurricane. The 43-page emergency management plan had errors: typos and an outdated hurricane drill copied and pasted from the previous year.

The plan was approved by Broward County, anyway.

Last week, amid pressure to improve the state's hurricane response and prevent similar tragedies, a House committee released post-Irma recommendations, including new criteria for such emergency management plans. But the recommendations say little about how to increase oversight that might have flagged problems in the Hollywood facility's plan.

"The enforcement is just not there," said Brian Lee, a former state long-term care ombudsman who now directs a long-term care residents' advocacy group. "The evaluation of the plans — the assessment of the plans — is pretty ambiguous."

Legislators say that more specific plans for oversight and enforcement will fall to committees that decide to craft or take up legislation based on the recommendations, or to rule-making that would task agencies with more responsibility. But it is unclear if or how many of those recommendations will make it from the report to legislation considered by a full chamber.

The Agency for Health Care Administration, which regulates hospitals, nursing homes and assisted living facilities, sets criteria for the emergency management plans that long-term care facilities must submit yearly to their respective counties. It falls to county emergency management offices to review and approve those plans. But in most counties, verifying those plans is little more than a paper check that confirms the plan contains the components mapped out by AHCA.

AHCA spokeswoman Shelisha Coleman said the agency "is reviewing the [hurricane] report, and we will work with any legislators that have proposals regarding the committee's recommendations."

In Broward County, where the Hollywood nursing home was based, staff members conduct a "paper review" of the plan after it is submitted to ensure that the plan meets requirements, said Miguel Ascarrunz, the county's director of emergency management. But those reviews do not verify what is self-reported in the plans. Hazard drills are conducted entirely by the facility, which also grades itself on those drills in after-action reviews.

After Hurricane Irma, the Broward emergency management division began conducting on-site visits, Ascarrunz said. But with a staff of fewer than two dozen, the division has only completed visits to the county's hospitals and about five of the 300 nursing homes and assisted living facilities.

The visits are also assessments more than inspections, Ascarrunz said. "The plan approval process is still a paper review, as long as they meet all the checklist criteria elements to include in their plan."

Angela Barton, senior planner for the Office of Emergency Management in Hillsborough County's fire rescue division, said her office had caught similar copy-paste jobs among the 350-odd emergency management plans that her staff reviews every year. But with eight full-time employees, "we just don't have the time to do a lot of followup with the facilities."

After the storm, Gov. Rick Scott issued emergency orders that required assisted living facilities and nursing homes to obtain generators and adequate fuel to maintain comfortable temperatures for at least 96 hours after a power outage. Another order directed emergency management agencies to re-review every plan, then post each to their websites within 10 days.

Those directives brought in so much paperwork that the Hillsborough office added three temporary workers, Barton said.

The report, from the House's Select Committee on Hurricane Response and Preparedness, sets out four recommendations pertaining to emergency management plans, including adding specific criteria for contact information and hardening plans, providing some information from the plans to family members and requiring that facilities submit their plans within 90 days after being licensed.

But the recommendations are much less specific on how to ensure plans are being read.

Rep. Chris Sprowls, R-Palm Harbor, said the report does not provide specifics so that committees can decide how to codify more oversight. "The recommendations are designed to be just that, recommendations to the committee," he said. "The actual legislation that comes out of the committee process will be far more prescriptive, specific about the issues."

Kristen Knapp, a spokeswoman for the Florida Health Care Association, the nursing home industry's trade group, said she was unsure if improving the requirements for emergency management plans would have made a difference at Hollywood Hills, faulting instead "a failure of management."

That nursing home, which was not a member of the trade group, did not have "anyone in management that was on site when these incidents occurred," she said, compared to other nursing homes whose administrators "hunkered down in their buildings with their staff."

Rep. Jeanette Nuñez, R-Miami, the chair of the hurricane select committee, said now that the report is complete, it is up to legislative committees to determine where the recommendations will go.

"Clearly there would have to be some rule-making" as well, she said.
Provided there is no special session, that means lawmakers have six weeks left to craft bills, have them heard by committees and voted on by both chambers if they want to address the report through legislation this year.

"Are they going to find someone who's going to sponsor this bill or propose legislation that would toughen up the requirements?"

Lee, the elder care advocate, asked. Right now, "these are nothing more than guidelines at best, and probably more like best practices… we don't even know if there's going to be a law."