Part 3-Hollywood Hills Nursing Home: Ticket #4301 | Part III – The State, the County and the Power Company

(Background) On Sunday, September 10, 2017, Hurricane Irma hit Florida. Among the places affected, was a privately-owned nursing home, 10 miles south of Fort Lauderdale, called The Rehabilitation Center of Hollywood Hills.  The nursing home lost power briefly in the storm.  While the electricity for the general nursing home systems kept working, separate electrical service to the air conditioning chiller remained out.  Temperatures rose dramatically during subsequent days.  On September 13, residents began to die. As of November 2017, twelve deaths were directly associated with the extreme overheating.  The manner of death was ruled homicide.  Investigation into the event is active and ongoing.

As soon as word of the tragedy spread, the Rehabilitation Center at Hollywood Hills nursing home was in trouble with the state of Florida.  The state Agency for Health Care Administration (AHCA), along with the governor, were stridently vocal about the nursing home’s criminal negligence.  As if it was the only answer, the only place to place 100% of the blame.  From their public statements, the state was completely clear of responsibility.  They began to produce logs, emails and documentation.  But the state’s responsibility may not be completely blameless.

Communication

One of the first areas to examine is the state’s role in communication.  The state Emergency Operations Plan shows a potential weakness in emergency planning.  There is no formal designation of support between Health and Medical Services (Emergency Support Function ESF 8) and ESF 12 Energy (fuel and power shortages).  The Governor got calls from the nursing home during the hurricane emergency, and turfed them to AHCA.

Why did the Governor give out his cell phone, if it was to mean nothing?  People had faith in this extra assurance, as the Governor surely intended.  But it served only to prolong a fruitless set of calls while the power company attended to other restoration efforts. In routing the calls to AHCA (and later turning off his phone), he could not count on a tight connection to and with the Energy sector.

That ticket #4301 was “escalated”, suggests AHCA asked FPL to move Hollywood Hills up on the priority list.  Was the request just computer entry or paperwork, or did someone actually call to get action?  If so, what response was given?  By contrast, AHCA did have designated support relationships with American Red Cross, Elder Affairs and the Florida Funeral Directors Association.

Require Generators or Not? A second key area is the question of generators.  The state conducts inspections and serves as eyes and ears for the federal government.

Federal regulations require facilities certified after October 1, 1990 to maintain air temperatures within a range of 71-81 degrees F.  Only during brief periods of time, those being “rare, brief periods of unseasonable weather”, could temperature exceptions be permitted.  Even then, a permitted exception would only apply where it didn’t negatively affect resident health and safety.  Further, staff were required to take appropriate steps to ensure resident comfort.  One could argue that Florida hurricane season is neither rare nor unseasonable.  For nursing homes certified after 1990, federal regs require “comfortable and safe temperature levels.”  By some reports, the temperatures reached 99 degrees in the days after the power went out.  In any case, the temperatures have proven to be neither comfortable nor safe.  Twelve resident deaths were ruled homicide due to “environmental heat exposure.”

At a state level, there was responsibility to assure appropriate inspection and follow-up. When Hollywood Hills got its power back, it did not get back the power for its air conditioning chiller.  Ideally, a back-up generator would have kicked in.

The Florida Agency for Health Care Administration (AHCA) had previously cited generator problems at Hollywood Hills.  Among the problems in a February 2016 inspection report, were citations for maintenance and testing.  AHCA further noted that rules require all equipment be permanently installed.  However, the nursing home’s emergency generator in early 2016 was a temporary generator.  They responded that architects had been hired, drawings were in process, and they would be submitting the installation plans to the AHCA Office of Plans and Construction.  In fact, progress was being made.  While it took some time, AHCA gave its approval for the revised construction documents on August 23, 2017, less than three weeks before the hurricane hit.

Even if the new generator had been installed before Hurricane Irma, it wouldn’t have helped the residents of Hollywood Hills.  The new emergency generator was only intended to support “basic life safety systems such as ventilators, fire alarm, egress lighting and nurse call” – just like the old one.  The generator was not required to power the air conditioning chiller.  Despite efforts to make improvements after the monumental 2005 hurricane season with Katrina and Wilma, no significant change was made.  Lessons learned were discussed at a 2007 summit.  But politics kicked in, and status quo was maintained.  Nursing homes simply were not mandated to have a generator supporting air conditioning.

This time, the governor declared an “emergency rule” after Hurricane Irma, to go into effect by November 15.  It would require nursing homes to have generators and sufficient fuel to power the air conditioning for 96 hours.  The rule was later suspended, due to the impossibly short time to implement it.  Eventually, however, leaders anticipate the state will find a way to enact this new standard.  On October 31, 2017, Hollywood Hills submitted its paperwork to begin compliance with the emergency rule, showing its plans for a dedicated generator to power the chiller.  (They proceeded even though their license to operate was suspended.)  Unfortunately, any implementation now will be too late for the residents who lost their lives.

Power Priorities as an Alternative to Generators

Questions have been appropriately raised about Florida Power & Light (FPL) restoring power to Hollywood Hills, and to nursing homes in general.  Sadly, nursing homes weren’t considered critical facilities for power restoration.  Broward County used FPL guidance in drawing up the list of what was considered critical.  FPL defined nursing homes as “non-critical”, but added they “play a decisive role in community recovery after a serious event.”  The definition is flawed in suggesting nursing homes are only decisively important “after” a serious event.  It fails to recognize the frailty and vulnerability of the nursing home population.

According to the most recent National Nursing Home Survey, 82% of nursing home residents in the US either didn’t walk in the past week, or had to receive help walking.  Nearly 2/3 (63%) were incontinent.  Nearly 1/3 (32%) had a mental disorder or Alzheimer’s disease at the time of the interview.  And nearly half (48%) took 9 or more medications.  This is a very frail population that is critical to care for.  The 2007 Nursing Home Hurricane Summit recommended that nursing homes be designated as healthcare facilities, as indeed they are.  Recommendation #2 said “These facilities must receive the same priority status for restoration of utilities (e.g. power, phone service) as hospitals…”

The power company and government had ten years to consider this recommendation.  Yet, Broward County did not challenge FPL’s nursing home definition as non-critical.  Fear exists about requiring senior facilities to be moved up in priority, because there are so many facilities.

In Florida, there are close to 700 nursing homes.  They all have vulnerable populations.  Many legislators also – perhaps mistakenly – merge in some 3000 assisted living facilities with the nursing homes when it comes to thinking about generators.  In doing so, the sheer number of facilities is daunting.  The utility fought being required to restore power to so many priorities at once.

Broward County and FPL were working together.  So too, did the state work with the utilities.  What obligation might the state have to assist with prioritization?  What obligations do the governor’s office and legislature have, to follow-up on lessons learned and to consider recommendations that come out of the summits?  Governor Scott came into office in 2011 – six years after Wilma, but six years before Irma.  How does Florida – or perhaps any state – display its leadership in non-crisis periods?  Do governmental leaders prioritize well in a decade “between killer hurricanes”, so to speak?

Once Hollywood Hills was emptied of residents, FPL arrived to fix the transformer on the outside power pole.  It took about 20 minutes to restore power and close out ticket #4301.

Reimbursement

A final area for the state to consider, is a broad one that applies to all nursing homes in Florida.  It also applies to every state in the US.  It’s the question of Medicaid reimbursement policy.  Based on the 2017 health inspections, Hollywood Hills rated just one star out of five, in the bottom 20% of nursing homes in Broward County.  At Nursing Home Compare, a 1-star rating on health inspections is considered “Much Below Average”.  With such an abysmal rating, how does the state justify continuing to permit Medicaid patients to be there?  Should the state not share the risk of this decision?

It is obvious that tying reimbursement dollars to performance is fraught with complexity.  It is also a political problem.  The Florida Health Care Association estimates that more than half of 73,000 nursing home residents are covered by Medicaid dollars.  If even 20% of Medicaid nursing home residents were in sub-standard 1-star nursing homes, more than 7000 would need to find a better place to live and receive care.

After-action reports are needed for the state regarding its responsibilities to the residents of Hollywood Hills.  The long term care ombudsmen and state legislature should see that it happens.

This is a 4-part case study for management, boards and emergency management planners:

PART I – The Tragedy at Hollywood Hills

PART II – The Nursing Home and its Emergency Plan

PART III – The State, the County and the Power Company

PART IV – Nursing Home Ratings – Can Consumers Trust Them?