The state Department of Health (DOH) is not adequately overseeing adult care facilities, risking the health and safety of vulnerable residents, according to an audit released today by New York State Comptroller Thomas P. DiNapoli. The audit found DOH at times failed to conduct timely inspections and often lacked documentation to show critical problems were corrected.

“Adult care facilities across the state have a responsibility to protect residents and deliver quality care,” DiNapoli said. “Regular and routine inspections of these facilities, and correcting problems, ensure residents are not left in unsafe or unsanitary conditions. If the state Department of Health isn’t conducting timely inspections or following up to make sure violations are corrected, then vulnerable residents could be left at risk.”

Adult care facilities are primarily home to the elderly who can no longer live independently, but do not require the care of a nursing home. These facilities provide housing, meals and personal care for individuals who need help with daily activities. All facilities must be licensed, and DOH is required to supervise them through regular inspections and complaint investigations. As of 2023, there were 534 adult care facilities operating in New York, serving 37,547 residents.

The audit reviewed DOH’s oversight of these facilities from January 2018 to October 2024. Health and safety issues at facilities can include, but are not limited to, inadequate staffing, call bells not functioning, no clear emergency shelter plans or the presence of mold, mice or bed bugs.

Delayed Inspections

The audit found DOH failed to complete inspections within the required 12- to 18-month timeframe at 70% of the 30 sampled facilities, with some delayed by as much as five years. Three of the state’s four regional oversight offices had inspection backlogs – New York City, Long Island and Western New York – while Central New York had no backlog.

Auditors conducted site visits at 20 of the sampled adult care facilities across the state and found a range of serious health and safety issues, including:

• Crumbling stairs and walkways;
• Dishwashers that didn’t reach safe temperatures;
• Refrigerators that weren’t cold enough; and
• A lack of regular fire drills.

Auditors also found additional unresolved problems:

• Expired medication present four years after a prior citation;
• Staff still uncertified in basic first aid more than 13 months after being cited; and
• A half-empty vodka bottle in a medical room and marijuana paraphernalia in an administrator’s office.

At one adult care facility that had not received a full inspection in nearly two years, auditors found issues that posed immediate risks to residents’ health and safety. DOH officials were notified and immediately performed a full inspection of the facility, resulting in a total of 54 violations and 12 findings.

Violations Not Fixed

DOH failed to document whether facilities corrected violations identified in prior inspections. Of the 89 violations reviewed in 30 inspection reports, auditors found no evidence DOH took corrective action. At 18 of 20 facilities visited, problems cited in earlier inspection reports were not fixed. In some cases, DOH inaccurately recorded partial inspections as full ones, causing further delays in oversight. Without proper follow-up, violations may continue for years and facilities may not be held accountable, risking patient safety.

Complaints Mishandled

DOH received 7,440 complaints and completed 6,498 complaint investigations from 2018 through 2023. Auditors found DOH failed to fully investigate some complaints or adequately document its investigations. In a sample of 130 complaints, 18% of allegations had no evidence they were investigated. This includes three complaints with 25 allegations that did not have evidence of any investigation at all. These complaints included allegations of poor care, such as residents confined to their rooms and waiting in hallways for long periods of time for assistance, a lack of resident supervision and dirty or poorly maintained facilities.

Recommendations

The audit recommends that DOH improve procedures to ensure timely inspections, follow-up on violations, complete and document complaint investigations and communicate findings promptly. It also calls on DOH to improve the accuracy of its data by regularly reviewing and updating information in its tracking systems and ensuring inspection records are complete and categorized correctly. These steps would help DOH better monitor facility compliance and identify delays in oversight. DOH should also address staffing shortages that have contributed to oversight delays.

DOH acknowledged delays in inspections and correcting violations, citing staffing shortages and the COVID-19 pandemic as major challenges. Officials said they have increased hiring, improved tracking systems and created a quality assurance committee to strengthen oversight moving forward. DOH’s response is included in the audit.

Audit
Department of Health Oversight of Adult Care Facilities