After spending nearly three years designated as a Special Focus Facility by the U.S. Centers for Medicare and Medicaid Services, Legacy Hilo Rehabilitation and Nursing Center was removed from that list last year.
Special focus facilities are nursing homes with a history of consistent quality issues that are under increased scrutiny by CMS.
While under previous ownership, Legacy Hilo was in jeopardy of losing its Medicare certification after inspections in 2016 found widespread problems with “substandard quality of care and harm.”
The 100-bed facility was added to the SFF list in July 2017 and graduated from the list in April 2020.
“We have implemented policies and procedures to ensure our quality measures, staff education and infection control targets the highest level of care,” said Administrator Justin Morrison in a statement recently provided to the Tribune-Herald. “Overall, Legacy Hilo has improved by two stars and has been removed from the SFF list.”
According to the CMS website, the facility currently has an overall two-star rating in the agency’s five-star quality rating system, which is based on a nursing home’s performance in three areas: health inspections, staffing and quality of resident care measures.
It currently has a one-star rating for health inspections — which evaluates the current and two prior health inspections, and three years of complaint and infection control inspections — but five stars in staffing and four stars in the quality of resident care.
Legacy Hilo’s most recent annual inspection, conducted Feb. 7, 2020, found eight deficiencies, all of which affected “few” to “some” residents and caused, or had potential to cause, minimal harm.
However, no complaint inspections were completed between Feb. 1, 2020, and Jan. 31, and no deficiencies were found in infection control surveys completed in May and September 2020, according to the CMS website.
When discussing Legacy Hilo’s four-star quality rating, Morrison said the facility has a full-time inpatient physician and nursing team that meet daily to address the needs of residents, as well as weekly quality meetings to ensure the nursing home is meeting or exceeding resident care outcomes. Administrators also meet monthly to track trends in care and set goals for residents.
“This facility is currently rated 5-stars for staffing to meet the needs of our residents and boast an excellent staff-to-patient ratio to ensure we are responding to their personal health needs in a timely manner,” he said.
According to Morrison, progress can be attributed to implementation of internal inspections the facility regularly conducts, based on similar factors CMS considers during its inspections.
“By doing this, our team can ensure that we are identifying areas of need and correcting identified deficiencies immediately,” he said. “We have also implemented a thorough infection control program and mitigation plan to reduce the risk of COVID-19 cases or other infections.”
Legacy Hilo, under its former owners, had filed for Chapter 11 bankruptcy in October 2019 and entered into a contract to sell the facility.
Oahu-based Ohana Pacific Health assumed ownership on Jan. 1, 2020.
“Legacy Hilo has always had a great team that has been passionate and dedicated,” said Ashley Takitani Leahey, director of communications and development. “The largest challenge has been transitioning to a new process and filling in the gaps of regulatory compliance information, where it was needed.”
Leahey said the facility has a leadership team in place that focuses on improving quality measures and resident satisfaction.
“The facility benefits from Ohana Pacific Health’s infrastructure, which provides support in all areas,” Leahey said.
Keith Ridley, chief of the state Department of Health’s Office of Health Care Assurance, which conducts all on-site state licensing inspections and Medicare certification surveys for CMS, said being removed from SFF status is a tribute to any facility.
“That’s a grueling status to be on, and when (Ohana Pacific) took over operation and ownership, they came with that baggage and worked to get the facility off that status.”
Although his division has a regulatory role, Ridley said he’s always pleased to see a care home make improvements.
“We continue to exercise the kind of scrutiny that’s required of us for any facility on a regular and ongoing basis to ensure the public remains safe, (and we) continue to look forward to their continued improvement.”
Email Stephanie Salmons at ssalmons@hawaiitribune-herald.com.
