The Los Angeles County Public Health Department falsified the dates it received complaints about nursing homes as pressure rose to meet state deadlines for launching investigations, according to two employees.

In a letter last month to county, state and federal officials,  inspector Kimberly Nguyen cited 11 cases in which she said the dates typed into the computer system were later than the dates the complaints were actually received. The cases mentioned in the letter involve alleged abuse, falls and pressure sores, she said.

“In my belief, falsification is a serious matter and unlawful and our department should know better to not manipulate paperwork to mislead others and the public,” Nguyen wrote in the Oct. 7 letter.

In an Aug. 6 email, Sharon Geraneo, an assistant supervisor in the department, also wrote administrators to protest alleged falsification of complaint dates. She wrote that the department cites nursing homes for fraudulent record-keeping and yet, “here we are falsifying the records.”

Under state law, investigations must be started within 10 days of receipt of a complaint— or 24 hours if the allegation involves the imminent threat of death or serious harm.  California Department of Public Health policy requires inspectors to enter the dates based on when the complaint was first received by telephone, fax, email or letter.

In Los Angeles County, the dates of some complaints were entered much later than when they were received — by as much as 79 days, Nguyen said.

Officials with the state public health department said they are investigating the allegations.

The Los Angeles County Department of Public Health issued a statement saying it has “zero tolerance for intentional document falsification” and is not aware of any deliberate falsification of records.

Department officials said they did identify a data entry error by one person that affected 35 cases. The error “prompted swift and appropriate corrective actions,” including re-training that staff member, according to the statement.

The health facilities inspection division “recognizes the importance of handling records in a timely manner,” the statement read.

Los Angeles County is under contract with the state to investigate potential problems at nursing homes, which typically are made by residents or family members, or are reported by the facilities themselves.

Both the county and the state have faced mounting criticism over the past several months for lax oversight of nursing homes. Legislative hearings, audits and reports have faulted public health officials for allowing thousands of open cases to languish,  often for a year or more.

The most recent allegations focus on problems at the other end — in starting the investigations. A state audit released last week said that in addition to the delays in finishing cases,  officials had not begun investigations within the required time frames.  In August, the Los Angeles County Auditor-Controller also faulted the county public health department for problems with entering complaints in the system days after receipt, rather than on the same day as required.

Nguyen said she believes the practice in some cases was deliberate, in part because it continued even after the August audit. She said she decided to speak publicly about her concerns because she believes the department is “putting patients in harm’s way” and should be held accountable.  She has made repeated attempts to get her superiors to address problems but said she has received little or no response.

“I’ve exhausted the proper channels,” she said. “It was time for me to come forward … This is a safety issue.”

In an interview, Nguyen said several cases concerned her, one of them involving Imperial Crest Health Care Center in Hawthorne. Documents showed the center submitted a report to the county public health department on Aug. 5, 2013 about a resident suffering a broken finger.  The receipt date, however, was listed as Aug. 16 — 11 days later. The investigation was begun within 10 working days after that.

The injury, which required stitches and a splint, resulted from an altercation in which a nursing aide snatched a mobile phone away from the patient, documents show. In fining the facility $10,000, the county said the facility had failed to intervene when the resident earlier accused the aide of being rough and asked for a different aide.

According to an Oct. 3 email, Nguyen raised concerns about falsified dates in other cases to her supervisor, Adewole Adegoke. In a response that day, Adegoke wrote that so much “behind-the-scene” work needs to be done before an investigation can be assigned and that the start dates are “not so black and white.” Also, the supervisor blamed a fax machine, saying it “had not really functioned as designed.”

Meanwhile, the state, which directly oversees nursing homes in every district except Los Angeles County, has had its own history of problems with timely investigations. A lawsuit by California Advocates for Nursing Home Reform, or CANHR, resulted in a 2006 order by a Superior Court judge instructing public health officials to follow the law regarding investigation timelines.

Geraneo noted that order in her e-mail to administrators, referring to a case involving a non-working generator in which the complaint year had allegedly been changed from 2013 to 2014. “We cannot change the initiation dates of these complaints because of the CANHR lawsuit!”

Geraneo declined to be interviewed.

Since Kaiser Health News began writing about the department’s health facilities inspection division in March, administrators have sent e-mails to staff telling them not to speak to the media and to forward all requests. Reached by phone, several inspectors have declined to talk, saying they feared retaliation.

Nguyen said  she has been she has been targeted for retaliation as a result of raising questions since July 2013 about the quality of nursing home oversight.

In May 2014, Nguyen was suspended for five days without pay because she allegedly failed to renew her nursing license. A department letter said her license expired on November 30, 2013 and that she worked for six days without a valid license.

But as the Board of Nursing later confirmed in writing, her license actually had been renewed promptly. The Board simply hadn’t entered the renewal on its website. Nguyen called the board on Dec. 11, as soon as she found out about the problem, and it was fixed within an hour.

The suspension occurred five months later — and just days after Nguyen said she provided evidence of allegedly improper case closures to the Los Angeles County Auditor-Controller.

Nguyen said she believes she was being punished by her bosses for exposing the department’s “unethical practices.”

“They were being vindictive,” she said.

A spokesman said the county public health department could not comment on personnel matters.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Supreme Court on Friday agreed to hear a case on a subject that’s important to millions of people who receive subsidies to help purchase coverage under the health-care law. Friday’s decision follows earlier action in July when two U.S. appeals courts issued conflicting rulings on the issue.  KHN’s Mary Agnes Carey answers some frequently asked questions about those court decisions and how they impact consumers.

Q: What did the Supreme Court do?

The justices decided to hear a case that challenges the federal government’s ability to provide subsidies to individuals in nearly three dozen states where the federal government operates the online marketplaces, or exchanges. There are several legal challenges on this issue that are working their way through the courts. The high court’s decision to accept the case surprised many analysts who thought the Supreme Court might wait until they had a ruling from the full District of Columbia Court of Appeals, one of the other courts considering the issue.

Q:  How did the lower courts rule on the subsidy issue?

A three-judge panel from the U.S. Court of Appeals for the District of Columbia Circuit ruled in July that the health law’s subsidies are available only to individuals in states now operating their own health insurance exchanges. In 2014, only 14 states and the District of Columbia ran their own exchanges, while 36 relied on the federal government. Judge Thomas Griffith, writing the majority opinion in the 2-1 decision, said they concluded “that the ACA unambiguously restricts” the subsidies to “exchanges ‘established by the state.’” That ruling was later vacated when the full District of Columbia Court of Appeals agreed to rehear the case, which is scheduled for December next month.

In a separate ruling, a three-judge panel for the Fourth Circuit Court of Appeals in Richmond, Va., ruled unanimously for the Obama administration, allowing subsidies to be available to residents in all states.  Judge Roger Gregory, writing the opinion, said while the health law is “ambiguous and subject to multiple interpretations,” the court decided to uphold the IRS’s interpretation of the law that residents of states using the federal exchange are entitled to subsidies. That Virginia case, King v. Burwell, is the case the Supreme Court said would hear this term.

Q: What was the issue the lower courts decided on?
The case centers on a brief description in the health law that says subsidies will be available “through an exchange established by the state.”

In implementing the law, the Internal Revenue Service (IRS) interpreted the law to allow eligible consumers to receive subsidies to help purchase coverage, regardless of whether they are in an exchange run by their state or by the federal government.

Opponents of the law questioned that interpretation, saying that the law as written clearly directs subsidies to state-based exchanges only.  But proponents – including several lawmakers who helped write it – said lawmakers fully intended that subsidies be offered on all exchanges no matter if they were administered by the feds or state officials.

Q: I live in a state with a federally run exchange, and I get a subsidy to help me buy coverage. Am I going to lose it?

Current subsidies will likely remain in place until there is a final legal decision on the matter.

White House spokesman Josh Earnest said the administration was confident it would prevail. “The ACA is working. These lawsuits won’t stand in the way of the Affordable Care Act and the millions of Americans who can now afford health insurance because of it,” Earnest said in a statement Friday. “We are confident that the financial help afforded millions of Americans was the intent of the law and it is working as Congress designed.” Open enrollment begins again Nov. 15.

Supporters of the court challenge to the IRS interpretation on subsidies also maintain their case is strong. “The Supreme Court’s decision is a rebuke to the Obama administration and its defenders, who dismissed as frivolous the plaintiffs’ efforts to defend their right not to be taxed without congressional authorization,” Michael Cannon, director of health policy studies at the libertarian Cato Institute who championed the subsidy appeals, said in a statement Friday. “It is essential that these cases receive expedited resolution, if only to eliminate the uncertainty currently facing states, employers, insurers, and taxpayers.”

Q: If there are legal disputes ongoing about who qualifies to receive a subsidy, do I still have to buy health insurance?

Yes.  The law’s “individual mandate,” which requires most people to purchase health insurance or pay a fine, is still in place and has been upheld by the Supreme Court.

Q. What if I get my insurance through work?
This decision applies only to policies sold on the online marketplaces. It does not affect work-based insurance, Medicare or Medicaid, regardless of where you live.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.