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Making Do With Too Little
Patients reap the damage from lack of oversight and inspections
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Published: February 7, 2005
The doctors and nurses who knew Abraham Crowe barely recognized him when emergency workers brought him to Cherokee Indian Hospital in March 2003.
Crowe, a blind diabetic confined to a wheelchair, was covered in dirt and had long, shaggy hair and fingernails so long that they had started to curl back into his fingers.
Worse, he had skin ulcers and was malnourished and dehydrated. Doctors determined that Crowe, 72, was a victim of elder abuse and neglect.
State investigators later determined that the home health-care worker who was supposed to take care of Crowe wasn't doing her job.
And nobody knew.
Unlike most other systems of health care - with layers of oversight and accountability -the typical home-care agency operates with few professionals monitoring how care is delivered.
Crowe's caretaker worked for Companion Health Care in Franklin, one of the more than 1,000 home-health agencies in North Carolina that don't usually face in-home visits by state inspectors.
The only time that such agencies are inspected is when the N.C. Division of Facility Services gets a complaint so serious that it merits an emergency examination of the agency's practices. There were 95 such emergency inspections in the most- recent fiscal year. But often, elderly or disabled patients aren't able to file a complaint, and loved ones who can often don't know how.
The state has seven home-health inspectors, some of whom have other duties in addition to their home-health work, said Azzie Conley, the supervisor of inspectors for the division.
Some state officials acknowledge that that's inadequate.
"I think we probably don't have enough inspections to oversee what's going on," said state Rep. Edd Nye, D-Bladen, a member of the Legislative Study Commission on Aging. "There's no question about the need for services, and the state has an obligation to see that they are carried out appropriately. What's going on now is we are expecting too many of them to inspect themselves."
State Sen. Jim Forrester, R-Gaston, agreed. "We probably need to do a little more monitoring of in-home health care because we spend a lot of money on it," said Forrester, a member of the Senate Appropriations on Health and Human Services Committee.
Asked why more inspectors haven't been approved, state legislators and administrators tend to point at each other.
Officials in the N.C. Department of Health and Human Services, the agency that oversees health care, say that the General Assembly hasn't provided enough money. Nye said that legislators haven't been asked.
Bob Fitzgerald, the director of the department's Division of Facility Services, acknowledged that but said the department had to make tough choices. "It's a matter of establishing priorities in a very tight budget," he said .
Carmen Hooker Odom, the secretary of the department, said she has sent a budget to the governor's office this year asking for five additional inspectors dedicated to home health care.
"Those legislators who are asking for a package to support are going to get one," she said.
Five additional inspectors would be enough to put all home health-care agencies on the same three-year inspection cycle that agencies offering more advanced care face, Hooker Odom said.
More inspections, however, may not be the answer to improving care, said William E. Lamb, associate director of public service at the UNC Institute on Aging. Instead, he said, the state should consider a star-ranking system similar to what child-care agencies have used since 2000. Home-health agencies that reach certain quality-of-care standards would be rewarded with more stars.
Because home health is such a market-driven system, the rating system would tend to improve standards of care more than adding inspectors, Lamb said. "If you're going out there to find an agency for your mother, would you pick a one-star agency or a five-star agency?"
The existing inspections system came under scrutiny in a 2002 report by the federal General Accounting Office. The report said the process was so flawed nationwide that it likely missed problems that could endanger the health and safety of patients.
For example, the report noted that inspectors in nursing homes may spend several days inside a facility, giving them a chance to watch caregivers interact with a large number of patients. With the large number of locations involved in home health care, however, inspections usually consist of reviewing medical records in the agencies' offices and visiting a small sample of patients.
A Journal analysis of North Carolina inspection data between January 2000 and July 2004 showed that inspectors found the most serious type of problems -those that pose the greatest risk of harming a patient - in only two inspections.
Those were in Diverse Home Health Services, based in Durham, and Total Care of North Carolina, based in Charlotte. In the later, a patient had to be hospitalized because of problems with care.
Diverse is no longer in business. David Causby, a regional administrator for Total Care, said the agency acknowledged the finding by inspectors and fixed the problems.
In rare cases, the division will revoke the license of an agency. That happened last year to Wilkesboro's Helping Hands Home Care Agency.
Inspectors found multiple problems at Helping Hands. Aides had not shown that they were competent to handle patients' needs, there were no written instructions for how to take care of four patients, and there was nothing in the staff files to show that criminal-background checks had been done for two of the agency's aides.
Database of nurse aides
Inspections aren't the only way that the state tracks problems in home health care. The Division of Facility Services also keeps a database of nurse aides who have been found to have misused their patients' trust.
Between January 2000 and July 2004, 17 nurses specially trained to look into such cases found:
154 cases of theft, including a woman from Wilson later charged by police in connection with the theft of a wedding ring, a diamond ring, a piggy bank and more than $1,000 in cash.
99 cases of fraud, including a Greensboro aide who was charged by police in connection with the forgery of almost $10,000 from her patient's accounts.
91 cases of neglect, including an aide from Concord who investigators determined left a patient with a male friend who molested the patient.
29 cases of abuse, including an aide who investigators determined pulled a chair from under her patient after telling the patient to sit down.
17 cases of stealing drugs from patients, including an aide from Dunn who investigators determined stole more than 100 pills of prescription painkillers from her patient.
Those incidents involved about 300 nurse aides, just a small fraction of the more than 20,000 such workers in North Carolina. But because many families don't know how to report problems, those numbers are likely to be underreported. "In a residential setting - a group home or day-care setting or a nursing home - you can post 800 numbers" to complaint lines, Hooker Odom said. "It's kind of hard to do in someone's home."
The system relies on the integrity of the agencies to report complaints against aides, said Jesse Goodman, who directs the registry for the Division of Facility Services. Agencies are required by law to report complaints within 24 hours.
Such a self-reporting system can confuse consumers, especially if an agency has many workers on the registry, Goodman said. "It could be that they are doing a good job of self-policing. Or it could be that they need to look at their initial screening" of applicants.
Terri Kern owns Personal Care Service, a Winston-Salem agency that has eight incidents reported on the registry. She said it shows her agency is acting with integrity. "I don't feel the need to brush it under the rug," she said.
It's difficult to know how workers are going to react when they go into someone's home, she said. "They are going into situations - sometimes of poverty, sometimes of affluence - that they have not experienced before."
Unlike patients in nursing homes and assisted-living homes, those in home health care don't have an ombudsman to help them when an agency's self-policing breaks down.
The state and federal governments require the program for the institutional settings. When problems occur, the ombudsmen serve as mediators between the patients and the homes caring for them.
Ombudsmen visit nursing homes and assisted-living homes to make sure that residents know who they are and what they do.
Sharon Wilder, the state's chief ombudsman, said the state can't create a similar program for home health care with existing resources.
The state has 27 ombudsmen who handle about 4,000 complaints a year. That is about 20 people fewer than is recommended for the number of patients in the institutions that her office covers, Wilder said.
"It would take a lot of money to set up an in-home ombudsmen program," she said. "Yeah, it's a great idea, but the funding for it and the manpower for it aren't there."
Reporting problems
Getting patients to report problems, though, can sometimes be difficult. In the case of Crowe, the man from Cherokee, investigators learned that he had grown afraid of his caregiver, Sherry Collins Maney.
Elizabeth Lauffer, a nurse for Companion Health Care, said that could explain why Crowe never complained about Maney when Lauffer checked on him every 60 days. She said she never saw any changes in his health or appearance.
Donna Martin, the office manager at Companion, said that the agency hired Maney at Crowe's request. Maney was the wife of Crowe's great-nephew. She was paid $7 an hour.
Martin said that the agency shouldn't be held solely responsible for not noticing Crowe's decline. "It's not like we go in there and do a strip search," she said.
Maney could not be reached for comment. She told investigators that she didn't understand why Crowe was found to be a victim of elder abuse and neglect. "He was taken care of while I was with him," she said.
No criminal charges were filed in the case.
Crowe never went back to home health care after he was taken to the hospital. He was instead transferred to a nursing home.
He died that August.
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