Complaints rise as states fail to meet care-facility inspection standards

The federal government’s most recent assessment of health-facility inspections indicates Iowa has failed to meet three key standards.

The new report from the Centers for Medicare & Medicaid Services indicates the state-run inspection agencies that oversee nursing homes and hospitals around the nation fielded more than 107,000 complaints about health care facilities last year. That’s a 31 percent increase from 2019, which officials say may have contributed to 38 states failing to meet all of the federal performance standards.

Each year, CMS assesses the performance of the state agencies tasked with enforcing federal regulations concerning health care facilities. The latest data shows that last year, only 14 of the 52 agencies met all of the acceptable thresholds for the annual recertification of nursing homes, according to the CMS State Performance Standards System Findings published this month.

CMS’ report indicates the Iowa Department of Inspections, Appeals and Licensing met most of the federal standards related to the inspection process in 2024, but failed to meet the standards in three areas:

Off-hour inspections at the worst nursing homes: Under CMS guidelines, state agencies are to inspect the worst care facilities in their jurisdiction — the federally designated “special-focus facilities” that have recurring, serious deficiencies in resident care — during off hours to guard against homes altering their routine in anticipation of what should be a surprise visit by inspectors.

Immediate jeopardy in acute-care settings: To accurately record the seriousness of deficiencies that can cause actual injury or death to residents in acute and continuing-care settings, inspectors must use a CMS-prescribed “immediate jeopardy template” in at least 80 percent of all cases where immediate jeopardy is cited. The template is used to document the evidence of each issue that places patients at risk.

Emergency Medical Treatment & Labor Act violations in acute-care settings: State inspection agencies must initiate, on a timely basis, the intake and investigation of at least 95 percent of EMTALA immediate-jeopardy complaints tied to acute and continuing-care providers. EMTALA violations often relate to emergency-room patients being discharged without first being stabilized.

Diane McCool, spokesperson for the Iowa Department of Inspections, Appeals and Licensing said the CMS report shows Iowa met the standard for conducting annual recertification inspections every 15.9 months, and that the agency not only met that standard but exceeded expectations.

“DIAL’s continued transparency and timely responsiveness reflect its commitment to safeguarding the welfare of Iowa’s most vulnerable residents,” McCool said. “Currently, there are zero nursing homes with more than 15.9 months survey interval in the third quarter and the state average is 11.54 months for the recertification.”

Complaints up 31 percent from 2019

In its report, CMS notes that its findings are to be considered “in the context of unchanged state-agency funding levels since fiscal year 2015, despite continued resource and workload challenges in the last five years.”

The report points out that since 2019, the number of complaints requiring investigation by health facility inspectors has increased 31 percent nationally. Most of the 107,000 complaints filed in fiscal year 20124 are related to nursing homes, CMS reported.

CMS also reported that during the past five years, there has been a 79 percent increase in complaints directed against hospitals, with more than 14,500 such complaints filed in fiscal year 2024.

Last October, DIAL issued a press release announcing that its health facilities inspectors had “met the federal mandate for nursing home inspections outlined by the Centers for Medicare and Medicaid Services (CMS) for federal fiscal year 2024.”

The press release focused on the federal requirement that each individual nursing home undergo an annual inspection, called a “recertification survey,” within 16 months of its last annual inspection. DIAL met that specific requirement in 2024.

At the time, DIAL also took issue with a September 2024 report from Auditor of State Rob Sand that indicated DIAL had failed to meet certain inspection standards. DIAL said the audit “relied on outdated numbers and incorrect federal performance measurements,” and the agency criticized the auditor’s office for failing to engage with DIAL “before issuing its inaccurate report.”

“The auditor’s report is inaccurate, incomplete, and confusing,” McCool said at the time. “It is also a waste of taxpayer dollars as the Center for Medicare and Medicaid Services will release their own findings of the state survey agencies after the federal fiscal year concludes.”

At least part of the conflict over the findings is due to the nature of the auditor’s report, which looked at DIAL’s compliance over three annual inspection cycles. DIAL itself focused more narrowly on data from 2024 when it performed better than in previous years.

The auditor’s report indicated Iowa had been conducting nursing home inspections, on average, every 17.1 months — which is more than four months beyond the federal mandate that requires such homes to be inspected, on average, every 12.9 months.

In addition to the federal mandate for inspecting all homes on a 12.9-month average, CMS also requires states to inspect each individual care facility at least once every 15.9 months.

According to the state auditor’s report, DIAL had failed to meet that requirement, as well. The report stated that for 85.4 percent of Iowa’s 403 nursing homes, inspectors missed the 15.9-month deadline on at least one occasion during the past three inspection cycles.

This article was first published in the Iowa Capital Dispatch.