by James C. Sherlock

Colonial Heights Rehabilitation and Nursing Center (Colonial Heights) is in the news again. New story, similar outcomes — a patient either dying or dreadfully injured — both ignored. The first time 18 staff members were arrested.

This time it was a physician who allegedly wasn’t even there. That was the problem.

In a brief summary of a riveting report from WRIC Richmond:

• Dr. Gohar Abbasi of Chesterfield is facing charges after a schizophrenic man with serious injuries was able to leave Colonial Heights Rehabilitation and Nursing Center with a catheter and a colostomy bag still in place.
• The victim is 33-year-old Timothy Holton of Colonial Heights. Court records indicate is homeless. But he wandered daily in the community. He was well known, reportedly gentle and liked there.

Dr. Abbasi was arrested and charged with abuse and neglect of a vulnerable adult with a bodily injury or disease.  

He was released on bond “without objection to travel to Islamabad, Pakistan from Jan. 23 to Feb. 14 to visit his elderly parents and attend his niece’s wedding.” Family man.

A chronological summary as reported with quotes in italics:

Mid-November 2024. Mr. Holton was in a car accident that left him severely injured.

Court records indicate (he) had displaced pubic rami fractures, a left sacral fracture, a large amount of blood in his pelvis, a nondisplaced T5-T6 spinous process fracture and many other serious injuries.

According to court documents, Holton was treated at Virginia Commonwealth University (VCU) Medical Center before he was transferred to the Hanover Health and Rehabilitation Center.

Holton was transferred once again to Colonial Heights Rehabilitation and Nursing Center for long-term care.

On Saturday, Jan. 11, Holton reportedly left Colonial Heights rehab at seven in the morning,

Citizens reported Holton could barely walk — he was stumbling and, while he was not falling down, his steps were very unsteady.

On Thursday, Jan. 16, Abbasi was arrested and charged with abuse and neglect of a vulnerable adult with a bodily injury or disease.

Court records show a nurse contacted Abbasi about Holton’s condition and that he signed himself out, but Abbasi could not remember the nurse he spoke to.

A family member said: “It’s really frustrating because, how can you just — if anyone read [Holton’s] medical chart, they would know his diagnosis and everything he’s been through — just at VCU alone — since November, and they would know that he’s not capable of leaving and he could barely walk …”

Observations. In this case there are two signals we will pursue further here:

• “If anyone had read his chart.”
• “A nurse contacted Abbasi about Holton’s condition and that he signed himself out, but Abbasi could not remember the nurse he spoke to.”

A basic question: “How often are physicians physically present at Colonial Heights?”

Prosecutors will have to make that determination about Dr. Abbasi with interviews. They cannot get a definitive answer either from facility payroll data or from any information currently available to Virginia’s Department of Health (VDH) or Department of Medical Assistance Services (DMAS).

The question is bigger than just Colonial Heights.

The federal Social Security Act requires specified physician services in nursing homes.

• “A physician must personally approve in writing a recommendation that an individual be admitted to a facility.
• Each resident must remain under the care of a physician.
• A physician … must provide orders for the resident’s immediate care and needs (Note: exceptions are described to orders by physicians. None apply here with the possible exception of dietary orders.)

Further details of physician requirements are below.

The Commonwealth has the responsibility to make sure that physician services are provided in compliance with the law. Indeed, the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities uses the term “physician” 62 times.

State surveys occur in Virginia about every two years rather than the one-year interval prescribed because of decades-old personnel shortages in the VDH Office of Licensure and Certification (OLC).

To make the determination of physician presence in nursing homes across the state, special efforts will be necessary.

Physician Services defined. There are specific requirements in the Social Security Act for physician services in nursing homes. Key provisions for this discussion include:

(a) Physician supervision. The facility must ensure that –
    (1) The medical care of each resident is supervised by a physician; and
    (2) Another physician supervises the medical care of residents when their attending physician is unavailable.

(b) Physician visits. The physician must –
    (1) Review the resident’s total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;
    (2) Write, sign, and date progress notes at each visit; and
    (3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

(c) Frequency of physician visits.
    (1) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
    (2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.
    (3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.
    (4) At the option of the physician, required visits in SNFs after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (e) of this section. (Note: Those personnel are advanced practice registered nurses (APRN). They are not generally permitted to assume this task independently in Virginia. In the case of physician delegation to APRNs, it would not matter anyway in these 118 facilities. Only one reported any APRN time.

(d) Availability of physicians for emergency care. The facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.”

Physician services in Virginia.

The delegation of physician services in nursing homes as permitted in subsections (e) and (f) above under certain defined circumstances with state approval is generally prohibited in Virginia. In the case of the delegation by physicians of dietary orders, which may be permitted here, only 17 of 118 reported dietician hours.

One hundred eighteen of Virginia’s 290 nursing facilities (40%) recorded zero physician minutes on their payrolls in the three months of Q2 2024 (last available data).

Unsurprisingly, Colonial Heights Rehabilitation and Nursing Center appears on the list.

Two Excel views of those data are provided.

One shows the physician-related Q2 2024 Payroll Based Journal daily non-nurse staffing of all Virginia nursing homes that reported no physician time. You will see that they reported very little staffing even in positions potentially supportive of physician tasks.

A second shows broader data about each of those facilities to put their payroll-based reporting of physician data in context with nurse staffing. They are sorted by Affiliated Entity Name. Regular readers will recognize that the first 51 of them are owned and managed from those two small areas of New Jersey discussed previously in this series. The Medicare staffing ratings seen there exclude non-nurse staffing including physicians. But the for-profit facility staffing ratings are awful enough without it.

Payments. Medicare and Medicaid pay each nursing home per diem for each patient based partially upon the facility’s assessment of patient acuity. That payment is supposed to pay for all of the patient’s needs, including physician services.

But physicians can be paid in ways that do not show up on individual facility payrolls. As example, a chain (affiliated entity) can keep physicians on corporate payroll to provide services to their facilities.

Verification of physician presence. The Center for Medicare and Medicaid Services (CMS) is unable to verify from the data it collects whether physician services are provided by a doctor who is not on the facility payroll or by an APRN on the payroll. For that reason those services do not count towards Medicare staffing star ratings.

As a result, Virginia citizens do not know if physicians actually show up in those 118 facilities.

What to do? The case of Dr. Abbasi and Colonial Heights Rehabilitation and Healthcare Center offers a cautionary tale.

I recommend that the officials of the Commonwealth with responsibilities here, the Health Commissioner for VDH and the Director of Medical Assistance Services for Medicaid, jointly:

1. send a letter to each of the 118 facilities who reported no physician hours in Q2 of 2024. Require them to name the facility Medical Director and each other physician who provided Social Security Act-required physician services in person and otherwise in their facilities in Q4 of 2024;
2. then contact each of those physicians and determine: what days and hours per day they worked in person and otherwise in those facilities in Q4; whether the fees for those services were paid by the facility or by some other payer; and if by another payer, name the source; and
3. then report the findings to the public.

Citizens, the Commonwealth and the federal government will find out if there has indeed been “a doctor in the house” with sufficient frequency and duration to provide for patient care.

It may not be pretty.

But it will offer a basis for sanctions already at state government disposal (links above) that citizens demand.