It doesn’t get more cynical than this: the Iowa Department of Inspections and Appeals eliminated 10 of its 38 nursing home inspector positions, ostensibly to save money. In response, the state legislature appropriated funding for those jobs in the current fiscal year. However, department leaders still refuse to hire any more nursing home inspectors.

Clark Kauffman has the story in the Sunday Des Moines Register, and it’s worth clicking over to read the whole piece. During the final months of Governor Chet Culver’s administration, the Department of Inspections and Appeals hired additional 10 nursing home inspectors. Attrition and budget cuts over the years had reduced the number of inspectors, and a 2009 report by the federal Government Accountability Office exposed Iowa’s shameful record of external pressure on those enforcing rules on nursing homes.

Governor Terry Branstad saw a different problem. In his view, the Iowa Department of Inspections and Appeals took too much of a “gotcha” approach to regulating nursing homes. He put former State Representative Rod Roberts in charge of that department, even though Roberts had not applied for the position and lacked “staff management or regulatory experience.” Roberts and his wife also had ties to care facilities in Carroll.

Roberts quickly cut the 10 nursing home inspector positions his predecessor had added a few months before.

According to Kauffman’s latest article, state legislators appropriated an extra $650,000 to the Department of Inspections and Appeals’ Health Facilities Division for the 2012 fiscal year. Democratic State Senator Jack Hatch, who chairs the Iowa Senate Health and Human Services Appropriations subcommittee, told Kauffman that the department agreed to restore the inspectors’ positions. Democratic State Representative Pam Jochum told Kauffman that legislators made their intent clear in allocating the funding. However, the text of the appropriations bill “didn’t specify that the money had to be spent on inspectors’ salaries,” Kauffman writes. Note to lawmakers: next time, don’t assume Branstad administration officials are negotiating with you in good faith. Legislative intent means nothing to them:

Inspections and Appeals spokesman David Werning said the department has become more efficient this year, in part by having some inspections handled by nurses who would otherwise be working strictly as program coordinators. There is also less “mirco-managing” in the system, he said.

“The bureaus that deal with long-term care facilities – the nursing homes – are, right now, probably about 50 percent ahead of their workload,” Werning said. “We aren’t behind on anything in terms of long-term care inspections. I know that raises the question of whether there ever was a need for those 10 positions. Frankly, probably not.” […]

Werning said last week that two-thirds of the $650,000 appropriation will be used to support the general operation of the department’s Health Facilities Division, which regulates hospitals, nursing homes and other care facilities. […]

The new money appropriated by the Legislature is cash recovered from companies that have committed Medicaid fraud. It’s the same pot of money the Culver administration intended to use for the 10 additional nursing home inspectors.

‘One-time source’ vs. ongoing expense

Although that fund has grown by several million dollars in the past year, Branstad and Roberts said it shouldn’t be used to pay for inspectors’ salaries since the money represents a “one-time source” of revenue and the inspectors’ salaries represent an ongoing expense. Now, however, the department will use the money to pay the salaries of other departmental staffers.

Werning said Roberts would have preferred to use state general fund money, but that’s not possible because of the way the appropriation was crafted by the Legislature.

Predictions:

Branstad won’t criticize Roberts for using a “one-time source” of revenue to fund permanent positions, as long as nursing home inspections remain few and far between. The governor appears to have no ambition to improve on his embarrassing past performance in regulating care facilities.

Republican state legislators won’t complain about department officials using appropriations however they wish. Iowa House Speaker Kraig Paulsen considered Culver’s director of Inspections and Appeals “a detriment to the state of Iowa.” Lawmakers from both parties have reduced fines for nursing home care violations and engaged in the political pressure exposed by the 2009 GAO report. (Note: Iowa is “State A,” discussed on pages 40 through 42 of that pdf file.)

Kauffman will have no shortage of material for Des Moines Register stories like this one about unnecessary deaths and serious injuries at nursing homes. I would hesitate to put a loved one in any assisted living facility in this state unless a relative or close friend were able to check on his or her care frequently.

Share any relevant thoughts in this thread.

P.S. I’m not comforted by Werning’s assurances that the department is now ahead of schedule on nursing home inspections. There’s good reason to question whether their schedules adequately protect patient safety:

The Des Moines Register reported earlier this year that the department now inspects stronger hospice facilities on a schedule of once every 20 years. The agency exercises no oversight of privately run home health agencies; is unable to impose fines of any size on hospitals or hospital-owned nursing homes; is years behind in the inspection of dialysis treatment centers; and doesn’t require licensing or government inspection of outpatient surgical centers.

The department also changed its restaurant inspection policies this year, meaning that facilities deemed “low risk” may be checked by state or county inspectors only once every two years.

UPDATE: A Des Moines Register unsigned editorial criticized Branstad’s stance on nursing homes but argued,

Adding more nursing home inspectors wouldn’t necessarily better protect nursing home residents – not if the message being sent to regulators by the Branstad administration and its actions is to befriend nursing homes, rather than regulate them.

The editorial also paraphrased Senator Hatch as saying that next year, “he plans to specify exactly how agencies are supposed to spend money because he said the Branstad administration has proven it can’t be trusted to follow the Legislature’s intent.”