As the coronavirus pandemic began sending waves of COVID-19 patients to hospitals early last year, the federal government ordered states to inspect the facilities with an eye to measures that would curtail spread of infection.
Georgia didn’t do the inspections, one of 13 states that simply did not comply, according to a report this week by the U.S. Health and Human Services Department’s office of the inspector general.
Officials with the Centers for Medicare & Medicaid Services, which oversees hospitals’ compliance with federal regulations, also asked accreditation organizations to do the special targeted infection-control inspections but couldn’t require them to do so. None did, even as controversies raged nationwide about whether hospitals were adequately protecting their workers and patients from the virus.
That left many crucial decisions about protections, processes and procedures to individual hospitals, and CMS could not ensure that they could provide quality care and operate safely during the pandemic, the report says.
The Georgia Department of Community Health, which is responsible for hospital inspections in the state, said it focused the resources it had on inspecting nursing homes, which CMS had made a top priority.
The Georgia Hospital Association did not respond to questions about the report.
Other advocates say hospitals were focused on managing pandemic response and had bigger fish to fry at the time than shepherding an inspector when staff were needed for all-hands-on-deck pandemic work.
But the inspections mattered, the report says.
“Hospitals that cannot control the spread of emerging infectious diseases within their facilities risk spreading a disease such as COVID-19 to patients and staff,” the inspector general found.
“CMS could not ensure that accredited hospitals would continue to provide quality care and operate safely during the COVID-19 emergency, and cannot ensure quality and safety at accredited hospitals when a future emerging infectious disease threatens the United States.”
A history of delay
For years, Georgia has lagged on inspections of health facilities. The situation became more dire last year, as COVID-19 cases and deaths mounted.
Last spring, CMS ordered all states to conduct on-site targeted inspections of nursing homes. Georgia was among the last states to complete the inspections, wrapping them up by the July 31 deadline to avoid financial penalties.
The Department of Community Health told the AJC at the time that those delays resulted from a shortage of inspectors, with nearly half of its inspector positions vacant.
The state has previously struggled to keep qualified staff in the health bureaucracy field, sometimes offering wages that are below poverty level for a family of four.
When it came to the hospital inspections, the federal government was trying to be prepared.
Because private accreditation organizations check standards at some 4,200 U.S. hospitals, CMS in March 2020 asked them to see if those under their purview were taking appropriate measures to control the spread of the coronavirus.
But CMS doesn’t have authority over the independent organizations, and the organizations didn’t conduct any on-site inspections as of January 2021.
The Joint Commission, a major U.S. accreditation organization, told The Atlanta Journal-Constitution in a written statement that it “could not perform surveys on-site at a time when our surveyors might be endangered.” Instead, it said, it relied on a virtual survey process at hospitals it accredits.
Because CMS pays state agencies to do inspections and can prioritize their workload, it did direct them to conduct infection-control surveys at the 500 hospitals they certify, and to prioritize complaints about infection-control problems at accredited hospitals.
Some states did a limited number of the infection-control inspections between March 2 and Aug. 17 of last year. But as of the August date, 13 states, including Georgia, had done none.
By March of this year, six of the 13 states have done some infection surveys, according to the inspector general’s report. It does not name the six states.
However, the DCH website does not show targeted infection-control inspections at Georgia hospitals since March 2020. A DCH spokeswoman said that the agency’s current priority for acute care is investigation of pending complaints.
The inspector general’s report does not say whether CMS sanctioned any states for failing to do the hospital inspections.
Infection control crucial
A consultant who represents some smaller Georgia hospitals, Jimmy Lewis, said that hospitals were motivated on their own to do premium infection control during the pandemic, implementing measures such as requiring constant high-level mask wearing and shutting out visitors.
“If they were unsafe, were they unsafe because they didn’t do inspections?” Lewis said. “My gut feel on that is no.”
From Lewis’ viewpoint, the major infection-control preparedness problem was instead at a level far above hospitals: There turned out to be no national emergency stockpile of supplies.
An advocate for hospital infection-control workers said that rote, pop-in inspections in the middle of the pandemic would be too late to respond to major issues of the moment. That doesn’t mean the impulse is wrong, though, she said.
Linda Dickey, president-elect of the Association for Professionals in Infection Control and Epidemiology, said reviews by infection-control specialized staff are crucial, because hospital patient care staff are focused on other things. If systematic reviews aren’t done, and infection control professionals aren’t in place when the emergency arrives, infections can do worse damage.
“If that program is not strong, patients and staff are far more vulnerable to get an infection,” Dickey said. “It can be devastating.”
The inspector general did find that CMS had designed and implemented effective internal controls over emerging infection diseases, even though it lacked the authority to ensure hospitals were prepared. The report recommends that CMS make regulatory changes so during the next public health emergency it can require accreditation organizations to do special inspections, rather than just asking them to do so. CMS agreed.