Sat, Mar 29, 2008 (2 a.m.)

Chris Morris

In a state known for loose governmental regulation and oversight, Nevada’s agency in charge of inspecting medical facilities has failed to follow its own policy in conducting those examinations.

Facilities such as the Endoscopy Center of Southern Nevada — where unsafe injection practices led to six cases of hepatitis C and 40,000 patients being notified to get tested for potentially fatal diseases — have gone as long as 11 years without a full inspection, despite a state policy calling for inspections every three years and a federal recommendation that inspections be conducted at least every six years.

Only six of the state’s 50 ambulatory surgical centers have undergone full, unannounced inspections in the past three years. And 21 of the state’s facilities have not had a full examination in more than six years.

Since the news broke late last month of the unsafe practices at the Endoscopy Center of Southern Nevada, blame has been pinned on doctors, nurses, the Medical Examiners Board and the public itself for not asking enough questions.

The Licensure and Certification Bureau has not been immune from the criticism. Gov. Jim Gibbons called for the head of the agency, Lisa Jones, who had served for five months, to be removed. Legislators are calling for a full review of the agency’s responsibilities and practices.

From interviews with staff and reviews of state records a complicated picture emerges of an agency that appears overburdened with responsibilities and understaffed.

The bureau has 48 positions — 10 of them vacant — charged with overseeing 2,214 licensees, including nursing homes, medical labs and facilities for the mentally retarded.

Federal and state mandates require the agency to inspect some facilities annually.

The Legislature, meanwhile, has continued to add extra inspections for new types of facilities, sometimes with only tenuous connections to health care, such as halfway houses for parolees and recovering alcoholics.

While broadening the bureau’s responsibilities, the Legislature has reduced its workforce. In 2003, with fees from facilities not coming in as expected, the Legislature cut 17 positions. Even though in following legislative sessions some of those positions were reinstated, the bureau has failed to recruit and retain inspectors, in part because salaries haven’t kept pace with those of similar workers in other state agencies.

“It’s obvious we have not met our inspection survey criteria,” said Dianne Allen, a bureau nurse surveyor and supervisor. “It’s not because we were not doing our jobs.”

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In January inspectors from the Southern Nevada Health District, the Licensure and Certification Bureau and the federal Centers for Disease Control and Prevention went inside the Endoscopy Center of Southern Nevada to investigate a hepatitis C outbreak.

According to Health District investigators, nurses at the clinic were reusing syringes and using vials of medicine meant for one patient on multiple patients.

The bureau has faced sharp criticism for its response. The Endoscopy Center said it would change its policies, so the state did not pull its license, but assessed a $3,000 fine. Some legislators said the fine could have been much higher.

Bureau officials, relying on advice from the state attorney general’s office, said they could not shut down the Endoscopy Center. If, as state law allows, the bureau had pulled the clinic’s license to operate as an ambulatory surgical center, physicians at the clinic could have continued to perform medical procedures such as colonoscopies, operating the facility as a doctors’ office. As such, it would not have been subject to state inspections, officials said.

In addition, while state officials witnessed nurses reusing vials of medicine meant for one patient, they did not see nurses reusing syringes.

The licensure bureau, meanwhile, started surveying the infection control practices at all 50 ambulatory surgical centers in Nevada. Officials found major deficencies at six other facilities, including others where single-dose vials were used on multiple patients.

Why hasn’t the state been regularly inspecting ambulatory surgical centers?

Licensing and certification officials say their workloads are largely set by state and federal law.

Federal regulations require nursing home inspections every 12 months on average. Home health care agencies and intermediate care facilities for the mentally retarded must be inspected every three years. And state law requires that group homes be inspected every year.

In addition to those required inspections, the Licensure and Certification Bureau must respond to complaints. The agency receives about 1,000 a year.

New facilities — which must be inspected before opening — inevitably push back reviews of existing centers. That was the case recently when officials hurried to complete an initial inspection so that a dialysis center could open in Fallon.

“Residents of Fallon really needed that,” Allen said. “We tried to prioritize workload based on the public need.”

A notice by the bureau informs those looking for an initial inspection that they will have to wait six to 12 months for a license.

The bureau “recognizes that this delay may create a hardship and is working to establish additional resources in order to conduct surveys in a timely manner,” the notice says.

Before the hepatitis scare, ambulatory surgical centers were not a focus of the bureau’s attention, Allen said. “We just didn’t get that many complaints about them,” she said.

The bureau, which this fiscal year has a $10.7 million budget, is completely supported by fees that facilities pay to be inspected. So the bureau was not affected by the latest round of budget cuts ordered by Gibbons after a decrease in sales and gaming tax revenue.

That funding mechanism, however, does not insulate the bureau from budget woes. For most of the 1990s, the bureau did not seek fee increases, Allen said. By the time the 2003 Legislature met, fees were not keeping pace with expenses, prompting legislators to cut 17 positions, according to a summary of the session prepared by the Legislative Counsel Bureau.

Later that year, the state Board of Health approved sizable fee increases for the bureau. But even with the extra money, it still is trying to recover.

That’s in part because of the problem of attracting qualified surveyors, as evidenced by the agency’s 10 open positions.

Surveyors need to be registered nurses with at least a year of clinical experience or hold an advanced degree in a specialty, such as in nutrition or public health, said Martha Framsted, a spokeswoman for the agency.

So even though the Legislature last year overrode Gibbons’ opposition to new positions for the bureau and added six jobs, it only recently found two new nurse surveyors.

Allen said retaining workers also has been a challenge. In 2005 the state gave a 10 percent raise to most of its nurses. But that raise did not apply to the nurse surveyors who work for the bureau because they do not work directly with patients.

The resulting salary disparity caused three longtime nurse surveyors from the Northern Nevada office to leave the bureau for higher-paying positions elsewhere in state government, Allen said.

In next year’s legislative session, the bureau is sure to be a focus.

“The (bureau) is going to be at the top of the list this legislative session,” said Assemblywoman Sheila Leslie, D-Reno. She said legislators will look at inspections not only of ambulatory surgical centers, but also of doctors’ offices and other facilities.

State Sen. Randolph Townsend, R-Reno, chairman of the interim Legislative Commission, has asked for a full review of the state’s response to the Endoscopy Center controversy and what action should be taken. He wants those reports by early April.

State Sen. Joe Heck, R-Las Vegas, a doctor, has called for ambulatory surgical centers to be inspected annually.

And Richard Whitley, the administrator for the Nevada State Health Division, which oversees the Licensure and Certification Bureau, said his agency will be reviewing the bureau’s responsibilities.

“We want to look internally at what the (bureau) can do differently,” Whitley said.