Day 4: Washington State’s Quality Assurance Nurses Help Homes Improve
Part watchdogs, part advisors, they aid in fixing violations
By Jim DeBrosse
Dayton Daily News (OH) – Wednesday, December 8, 1999
(C) 1999 Dayton Daily News
TACOMA, Wash. – Gladyce Hurlburt, a quality assurance nurse for the state of Washington, is five minutes into her rounds at the Masonic Home Health Center when she notices a nurse’s aide helping a patient into a restraining chair.
Hurlburt, who knows the nursing home has been cited for misusing such chairs in the past, makes a note of it, then moves on.
Before she leaves the home that morning, she will ask the director of nursing and the administrator if they have carefully considered if the chair is necessary and safe for that resident.
`Why wait until a patient is harmed? That’s why I’m here, to help homes avoid problems and to learn to fix things for themselves,’ Hurlburt said.
Hurlburt’s job as a quality assurance nurse is unique to Washington – one reason the state has perhaps the best-run, safest nursing homes in the nation, according to national advocates for the elderly.
Hurlburt is neither an employee of the home nor a state inspector ready to hammer it for violations. Instead, her role falls somewhere in between: She is a state-funded advisor to the home, working both as a partner to improve its quality and as a whistleblower for the state – but only if she spots serious lapses in care that demand immediate attention.
Thirty-one quality assurance nurses each monitor eight to 10 nursing homes. They make unannounced visits to every home in Washington at least every three months, spending two or three days getting to know the staff and residents. Their visits are more frequent – sometimes weekly – in problem homes being monitored by the state.
Compare that supervision to other states, including Ohio, where regular inspections of nursing homes occur only every 12 to 15 months.
Advocates for the elderly say the Washington system should be a model for the nation – a combination of quick responses to complaints (most are handled within two to 10 days), tough and more immediate penalties for violators and a helping hand for troubled homes from nurses like Hurlburt.
`Washington is doing a better job (of assuring quality nursing home care) than any other state,’ said Bob Mollica, deputy director for the National Academy for State Health Policy, based in Maine.
Toby Edelman, a staff attorney for the National Senior Citizens Law Center in Washington, D.C., readily agreed with Mollica. `From what I’ve seen of Washington’s (enforcement) system, I’m ready to retire there,’ she said.
Washington’s quality assurance program “is the future,” said Kurt Haas, head of the long-term care inspections office at the Ohio Department of Health, “although not everyone in this department would agree.”
Cost is one issue, Haas said. Washington spends $1.5 million a year to pay the 31 nurses who monitor a total of about 275 nursing homes. Ohio has about 940 nursing homes, which would more than triple the cost of such an effort.
Nor are Ohio legislators likely to toughen nursing home enforcement laws beyond the federal requirements so that regulators here can impose immediate fines for most health and safety violations, said Alan Curtis, chief of the state health department’s regulatory compliance division.
Most states, including Ohio, allow a correction period of up to 50 days before a nursing home is penalized. If the problems are fixed, the punishment is waived.
But in Washington state, penalties often take effect immediately when serious deficiencies are discovered, whether past or present. Homes face even stiffer penalties, and mandatory fines, if they fail to correct those deficiencies, or if the violations are repeated after correction within 15 months. Fines of up to $3,000 a day must be paid within 20 days of notice unless a hearing is requested.
In serious cases, the state immediately bans all new admissions – and essentially all new sources of revenue – until the home fixes its problems. To help the home accomplish that, quality assurance nurses make frequent visits.
But the Washington enforcement system is not just one of “cops and robbers, crime and punishment – the reality is far more complex,” said Gerald Reilly, executive director of the Washington Health Care Association, the trade group for nursing homes in the state.
Reilly gives more of the credit to the state’s adequate reimbursement for nursing home care (about $120 a day) and its quality assurance partnership with the state.
If annual state inspections are “the snapshot” of how a home is performing, the quality assurance nurse provides a slide show and the home’s own internal quality assurance program is the moving picture, he said.
“We have managed to get beyond the culture of confrontation” that permeates the enforcement system in most states, Reilly said.
The Masonic Home is a good example of how the Washington system of punishment and partnership works. For decades, the charming Mediterranean-styled facility, built in 1926 on a hill overlooking Puget Sound, operated as a private-pay facility for elderly residents with limited medical needs. Run by the same director of nursing for 25 years, the home had an excellent reputation – until three years ago.
That’s when the home began for the first time to accept Medicare and Medicaid patients, many of whom were sicker than any of the home’s previous residents. At the same time, a new, less experienced director of nursing took over the operation, and conditions at the home rapidly deteriorated.
Last December, state inspectors found enough serious violations at the home to cut off all new admissions there for more than two months. That, too, is when Hurlburt began making regular visits to the home to help it work out its problems – collaborating with both a brand-new director of nursing and a new administrator hired by the Masonic board.
By March, things had improved enough that the state lifted its stop placement order. But Hurlburt continues to cruise the halls on occasion as a friendly advisor and, if need be, a watchdog. If she sees problems that threaten patients, she can notify her district manager and call for an inspection.
The fact that Hurlburt is both advisor and potential whistleblower can be unnerving, nursing home officials admit. But at the Masonic Home, administrators say the help they get from quality assurance nurses far outweighs any potential citations.
`I’ve learned to use these people as a learning tool and not to fear them,’ said Debbie Sullivan, a charge nurse at the Masonic Home. `But they take getting used to and knowing exactly what they are looking for. They can’t tell you what to do. They can only make suggestions.’
Jean Burdick, director of nursing at the Masonic Home, said the quality assurance nurses she has worked with `get to know the staff, the residents and the building very, very well. It’s nice because they’ll point out things we need to look at.’
Burdick says she’s concerned that things may not run smoothly while Hurlburt is in the building `but I don’t sit there and bite my nails. I go about my day.’
Masonic Home administrator Diana Baum says her only complaint is that quality assurance nurses, who are often in the field, aren’t always available when she needs to reach them for advice.
`The quality assurance nurses are here to make sure we aren’t slipping,’ she said. `We both have the goal of excellence. We just look at them as people helping us reach that goal.’