Since the early days of the pandemic, Maryland Gov. Larry Hogan has sparred with President Trump — casting himself as filling voids left by the federal government when it comes to testing, personal protective equipment, ventilators and, more generally, leadership.

This week, it was the Trump administration rebuking Hogan (R). In a letter to the governor Wednesday, the director of the Centers for Medicare and Medicaid Services (CMS) decried Maryland’s failure to meet the July 31 deadline by which states had to complete coronavirus-focused inspections of nursing homes, adding that Maryland’s track record on those inspections was the worst in the country.

Across the state’s 227 nursing homes, more than 5,000 residents have tested positive for the virus and 1,133 have died — putting Maryland seventh in the nation in the number of per capita cases in nursing homes and ninth in per capita deaths in nursing homes, according to federal data.

The letter from CMS Director Seema Verma came the same day Hogan finished his term as chairman of the National Governors Association — a position he often used to blast the White House for failing to send more aid to states and not having a national testing strategy — and one day after Hogan announced the formation of a “compact” of seven states that would buy testing kits en masse.

Verma wrote that Maryland’s Office of Health Care Quality had inspected 55 percent of its nursing homes by the end of July, which she said had caused “extreme concern for the health and safety of Maryland’s aged population.”

“It is absolutely critical that you immediately prioritize the health and safety of your state’s nursing home residents by completing the Trump Administration’s required inspections for all certified nursing homes in Maryland,” she wrote in the letter, which was first reported by the Baltimore Sun.

Hogan spokesman Mike Ricci disputed that figure, saying surveyors have inspected 75 percent of the state’s nursing homes and plan to complete the remaining surveys in the next two weeks.

“It was the White House and Administrator Verma that praised Maryland for our early and aggressive actions to address nursing home outbreaks, including first-in-the-nation strike teams, which they recommended that other states emulate, and even emulated themselves at the federal level,” Ricci said in a statement.

He did not specifically address why Maryland did not meet the deadline, or that even at 75 percent, the state still has the worst track record on inspections in the country. Every other state, except for Alaska and Pennsylvania, is above 97 percent completion, according to the letter.

Ricci added that the Trump administration should instead focus on states experiencing spikes in new cases among their general populations and outbreaks in long-term care facilities, rather than Maryland, which Thursday reported a record-low positivity rate of 4.03 percent among state residents.

Critics have cited Hogan’s handling of nursing homes as a weak spot in his pandemic response, saying that despite big announcements — such as requiring universal testing and levying fines for failure to comply with regulations — the administration has missed important steps when it comes to protecting the state’s most vulnerable residents.

“It is embarrassing and shameful that the state hasn’t stepped up,” said state Sen. Clarence K. Lam (D-Howard), the lone physician in the state Senate. “It seems like despite all the great bluster from the governor, there has been a lack of attentiveness to detail and very real problems.”

Lam also cited the state’s decision to stop paying for testing of staff members at nursing homes as of Aug. 15 as another issue, saying that Hogan’s requirement for universal testing is useless if nursing homes say they cannot afford to pay for testing.

The intent of the coronavirus-focused surveys is to home in on infection-control issues that could contribute to the spread of the virus. Common mistakes include failure by staff members to properly wash their hands or to separate patients who had tested positive for the coronavirus from those who tested negative, according to public records reviewed by The Washington Post for Maryland and Virginia.

Joseph DeMattos, president of the Health Facilities Association of Maryland, which represents 150 long-term care facilities, said that such inspections are needed to reassure facilities that they are taking the correct steps to protect residents, and to alert them when mistakes are being made.

“Whether 55 or 75 percent is accurate relative to these inspections is irrelevant,” he said. “These inspections are vitally important, and the lack of them is a breakdown in leadership.”

Maryland’s Office of Health Care Quality, which is responsible for oversight of nursing homes, was cited by federal inspectors in 2017 for failing to investigate nearly 650 allegations of harm in those facilities within 10-day window established by federal regulations. That meant inspectors missed the deadline 74 percent of the time. Federal auditors also found delays in 1999, 2006 and 2011, according to the Sun.

In its annual report for 2019, the office said it had 58 surveyors for nursing homes. To meet the need for regular inspections, it predicted it would need an additional 13 surveyors — and that was before the pandemic.

“All of our abilities have been challenged to keep up with the demands,” said Allison Ciborowski, chief executive of Leading­Age Maryland, which represents 120 nonprofit operators of long-term care facilities.

She added that the Office of Health Care Quality was dealing with the logistics of conducting on-site visits, including ensuring officials had adequate personal protective gear and did not unintentionally expose residents or staff to the virus. Officials have previously said that inspections in Maryland were paused at the beginning of the pandemic for more than a month because of shortages of protective equipment.

Once they resumed, the state identified infection-control deficiencies at multiple facilities. In early June, the state released nine inspection reports in response to a public information request. Four of the nine facilities, which were inspected in April and May, were not in compliance with state and federal guidelines for the pandemic.

Maryland also has imposed heavy fines on at least two nursing homes for missteps in responding to the coronavirus crisis: Pleasant View Nursing Home in Carroll County, which was the site of one of the state’s earliest nursing home outbreaks, and Sagepoint Senior Living in La Plata, for not using appropriate personal protective equipment.

Ciborowski said inspections are important but are “just one piece of the puzzle. The other pieces are PPE and testing.”

She said the state recently offered to make discounted testing for staff members available to nursing homes through the University of Maryland Pathology Lab. But she said there have already been “huge challenges” for nursing homes trying to access that testing. She said that access to personal protective gear is better than it was in March, but still not readily available to some.

DeMattos’s assessment was more bleak: “In order to turn around another ramping crisis, what is critical is adequate testing and adequate PPE. Right now, we have neither.”

rebecca.tan@washpost.com