Florida’s seniors left vulnerable to hurricanes because generator requirements were not enforced

Sep. 9--As powerful Hurricane Dorian threatened Florida, thousands of elderly at nursing homes and adult living facilities were at risk in facilities without generators or back-up power.

It was a situation that Florida regulators had tried to correct in the wake of a dozen heat-related deaths at a Hollywood nursing home after Hurricane Irma, two years ago. Following those deaths, Florida changed its regulations to require backup generators and enough fuel to maintain comfortable temperatures at all of the 3,749 nursing homes and assisted living facilities in the state in the event of a power loss.

After an initial 60-day deadline, the state set a final deadline of June 1, 2018, for the nursing homes to get a generator, create and submit their emergency plans, and then pass an inspection. If a facility doesn't adhere to the new rules, the state could impose administrative fines or suspend the facility's license to operate.

Some complied, some did not.

Extension requests pile in

Nearly 60% of Florida's nursing homes and adult living facilities filed waivers, extensions and variances multiple times, asking for more time to meet the requirements. And some didn't respond at all.

Two days after Gov. Ron DeSantis declared a "state of emergency" in Florida for counties in Hurricane Dorian's path, the Agency for Health Care Administration's generator status map showed one in five Florida nursing homes or assisted living facilities were counting on temporary generators to be delivered before Hurricane Dorian hit -- and some had not communicated at all with the state about their generator status. The rules require nursing homes to bring temporary generators on site within 24 hours after the governor declares a state of emergency for counties in the storm's path.

"The luck of the weather spared us from having a harsh test of the state of our nursing home preparedness," said Dave Bruns, a spokesman for the Florida chapter of AARP, an organization representing people 50 and over. "We can't take much comfort from the fact we were lucky."

With Florida in the potential path of a major hurricane, the Agency for Health Care Administration scrambled to visit nursing homes and assisted living facilities around the state to check for compliance and onsite generators -- in some cases for the first time since the new rules went into place two years ago. About 190,000 people live in Florida nursing homes and assisted living centers, with the majority of them in South Florida.

"There are going to be site checks, there are going to be phone calls to make sure that they have a plan to deal with folks that are in their care," DeSantis said in a news conference.

The site checks begin

As Dorian escalated toward hurricane status, and with the entire state in the cone of uncertainty, the AHCA generator status website (http://fl-generator.com/) showed Florida nursing homes and assisted living facilities with more than 15,000 beds still had not met the requirement for back-up generators.

Mary Mayhew, secretary for the Agency for Health Care Administration in Florida, said her staff had been making ongoing efforts since April to ensure nursing homes and other facilities complied with the generator rules, but intensified its focus after DeSantis declared a state of emergency.

"We made hundreds of calls and site visits to support and verify their generator status," she said.

Kristen Knapp, communications director for the Florida Health Association, the state's largest advocate for long-term care providers, said the state's generator status site reflected that local emergency managers in some counties didn't have the manpower to visit and sign off on emergency plans, leaving the state to do the job.

"There also were delays in ordering equipment, getting enough generators and staff to complete the work," Knapp said. "We do recognize that at the end of day, resident safety is focus, those that didn't have permanent generators tried to have temporary ones. Generators make a huge difference. It's the right thing to do and every one is working toward that," she said.

Although listed on the Agency for Health Care Administration site on Aug. 30 as not having a generator, Victoria Villa in Davie, a 44-bed assisted living facility, actually had installed its generator over the summer and submitted an emergency plan.

Rita Collazo, office manager of Victoria Villa, said while her facility complied with state requirements, Aug. 30 was the first time anyone from the state visited to ensure the generator worked.

"We have two generators -- one for the facility and a small one for the air conditioner, and we started both in front of them," she said.

Cost emerges as a factor in delays

Ralph Marrinson, who operates three nursing homes in South Florida, believes some facilities failed to comply with the new rules because of the cost. Generators, particularly those that can power air conditioning units for a nursing home, are expensive, he said. Marrinson paid as much as $350,000 for each one he installed.

"Some of the mom-and-pops who own assisted living facilities can't afford that cost," Marrinson said. "It's not that they don't want to ... it's that they can't afford to be compliant."

Knapp agrees: "Generators are a significant investment. The average cost for a nursing homes is $350,000 up to $500,000 depending on how many beds."

She said about 60% of nursing homes get state money through Medicaid to offset patient costs. "Most had to take out loans to pay for generators ... they are not funded initially by Medicaid," she said. The cost, and the permitting involved, led some long-term care providers to ask for multiple extensions.

Mildrene Jeudy, who runs a six-bed assisted living facility in Miami called Love & Peace, admits she asked for several extensions and said it took eight months of working with a contractor -- and $16,000 -- to install a permanent generator.

"It wiped me out financially, but I think it will be worth it," she said. After the installation, no one from the state checked on its completion -- until Aug. 30 as the storm approached, she said.

Along with cost, Bruns of the AARP acknowledges that logistics played a role in the lack of onsite generators at nursing homes and assisted living facilities.

"It's not an easy engineering challenge to solve. Getting a generator the size of a semi-truck and fuel supply to supply it for 96 hours of operation is not the kind of thing you can do in the snap of a finger. But acknowledging that challenge doesn't help you if you are 90 years old and bedridden in one of those facilities. At end of the day, this comes down to safety," Bruns said.

On Sept. 3, as Dorian's track paralleled the coast and brought bad weather to the state, 36 providers with 1,278 beds still had no generators or emergency plans and 150 facilities -- large and small -- still awaited generators to be delivered. Yet, just a week earlier, four people were charged with crimes for the 12 patient deaths inside a sweltering Hollywood nursing home after Hurricane Irma.

"We have made considerable progress," Bruns of AARP acknowledged, "however, we need to close the gap."

Mayhew said she is working to do that. On Friday, as Dorian moved north of the Carolinas, the AHCA website showed 98% of Florida's ALFs had permanent or temporary generators and 80% of its nursing homes had permanent or temporary generators onsite that will cool the living space to at least 81 degrees.

With even one facility for the elderly without cooling ability post-storm a concern, Mayhew said she is cracking down on those still who don't have a generators:

"I have conveyed that we have got to focus on compliance with this rule," she said. "I am going to be reluctant to extend and grant variances beyond this year, unless they are able to demonstrate good faith and due diligence that the circumstance is beyond their control."

Mayhew said she also is working on surveying the large nursing homes and assisted living facilities to better understand the barriers that caused delays.

Evacuations became the executed emergency plan

In total, 95 nursing homes and assisted living facilities along the east coast of Florida were evacuated because of Hurricane Dorian. Mayhew told reporters that only four of the long-term care facilities were evacuated because they didn't have emergency generators and access to backup power as required by law.

Some nursing homes and assisted living facilities saw the size and strength of the hurricane and chose to evacuate to sister or partner facilities.

"They knew if the storm came close they would have flooding, and they looked at the track and got started," said Knapp with Florida Heath Care Association, the nursing home advocacy group.

On Friday, Mayhew, reiterated that evacuation decisions were made locally with county emergency management officials based upon the storm's track, a buildings' ability to withstand a major hurricane, and whether it was in a surge zone -- not on whether a site lacked a generator.

Evacuations may be a health risk

Evacuations with the elderly are tricky -- and should be a last resort, research shows.

Research published in a journal for the National Institute of Health shows removing frail seniors from their long-term care facilities can exacerbate existing physical and mental health conditions. In addition, residents with severe cognitive impairment who are evacuated are at increased risk of death at 30 and 90 days post-move."

"We don't' know yet, will have to see what the emergency management analysis shows about the trauma that resulted," Bruns said.

Mayhew said her team has begun wellness visits to nursing homes and assisted living facilities as residents are moving back in. As of Friday, not every senior had returned home.

By year end, Mayhew said she wants every long-term care provider to be in compliance with the generator requirement. Along with fines already imposed to 287 facilities, she is notifying those still out of compliance that their license is at stake.

To its credit, AHCA created a public-facing generator status website, FL-Generator.com, and put it up on Aug. 29 to ensure that the public had access to the most accurate information about what facilities had a permanent or temporary generator onsite, were waiting for the delivery of a temporary generator, or had plans to evacuate. A big focus going forward, Mayhew said, will be getting reliable and timely data about generators and emergency status information updated in real time and available to the public.

"Within this agency, I have created an internal list of opportunities for improvement," she said.

Cindy Krischer Goodman can be reached at [email protected], 954-356-4661, Twitter and Instagram @cindykgoodman

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