by James C. Sherlock

This is yet another story of state-sanctioned corruption by elected politicians serving the interests of the nursing home industry. New players, same play.

That industry, led this time by out-of-state chains, has once again found it cheaper to buy the votes and influence of senior members of the General Assembly with laundered Medicare and Medicaid funds than to spend that money to care for residents.

The Saga of General Assembly House Bill 605

An article by this author, published two months ago, drew attention to House of Delegates Bill 605 (HB605). The patrons were Delegates Rodney Willett, D-Henrico, and Vivian Watts, D-Fairfax. As introduced, HB605 set a minimum staffing standard.

It therefore had no chance of passage and may never have been expected to do so.

Rep. Willett introduced his bill on January 13, 2026. On that same day, he and Del. Luke Torian (Appropriations Committee Chair) received $10,000 each from Organizing for Virginia Seniors. Gov. Spanberger’s name, at $100,000, tops that list. Organizing for Virginia Seniors is funded by out-of-state nursing home chains.

Willett now says he will “defer to the greater experts” on determining standards.

As sent to the Governor, HB 605 directs the Joint Commission on Health Care to conduct a study. The only directed reference is to that Commission’s own 2021 study, not the wealth of national work on that subject. The nursing home lobby is confident that it controls the outcomes from that Commission. It always has. Money well spent.

That sequence of events is, unfortunately, legal in Virginia.

We’ll examine the industry positions on both regulations and sanctions, and some history. Then we will look at the General Assembly’s “greater experts,” who sit on and staff that Commission, including Willett, who chairs it.

No current standards

§ 32.1-127. Regulations. B. Such regulations: 1. Shall include minimum standards for (i) the construction and maintenance of hospitals, nursing homes and certified nursing facilities to ensure the environmental protection and the life safety of its patients, employees, and the public; (ii) the operation, staffing and equipping of hospitals, nursing homes and certified nursing facilities; 

Virginia regulations currently do not include minimum total nurse staffing standards. Follow the bouncing ball.

• An extensive 2001 study by the Centers for Medicare & Medicaid Services (CMS) proposed a standard of 4.1 hours per resident per day (HPRD) for total direct nursing patient care.
• In 2023, Virginia (SB1339/HB1446) required a minimum of 3.08 HPRD.
• That law had a self-executing sunset provision that took effect upon CMS’s establishment of standards, including 3.48 HPRD.
• Those rules did not withstand Congress, which repealed the standards under industry pressure.
• This year, a new Virginia standard, HB 605, as originally proposed by Chairman Willett, was 3.25 total nurse direct care staffing HPRD.
• That standard was replaced by the General Assembly with a study.

The lobbyist position

McKnights Long Term Care News, understandably, tunes its reporting to the sensibilities of its subscriber base, the nursing home industry. Kimberly Marselas reported on Willet’s bill and the response by industry lobbyist Virginia Health Care Association (VHCA).

While many providers remain generally supportive of some form of staffing requirement, Virginia Health Care Association Vice President of Strategy and Communications Amy Hewett said her organization is advocating for some changes to Willet’s bill — and critical funding — during its newly opened legislative session.

Hewett said operators support and previously agreed to the 3.08 hourly standard because it aligned with a threshold already set in the state’s value-based incentive program.

The bigger hurdle may be securing the money to fund higher staffing. 

“Funding is always part of the conversation related to staffing. Staffing is the largest expense in nursing home care,” Hewett told McKnight’s Long-Term Care News. “Part of the guardrails in the 2023 rule were such that, if the state were going to impose a mandate, it needed to fund it.”

Where to start with that narrative?

Willett’s change of mind has been explained, if “explained” is the word we are seeking.

The 3.08 hourly standard is accurately said to be “aligned with a threshold already set in the state’s value-based incentive program” because the General Assembly put it there at the direction of Ms. Hewett’s employer.

In a recent article, this author contested the thesis that Medicaid rates are insufficient by presenting evidence from Virginia nursing homes, including a long-participating for-profit facility, funded by Medicaid. There is enough money in that program for both resident care and a reasonable profit.

Out-of-state chains in Virginia 

A downloaded and corrected spreadsheet of this month’s CMS Provider Data for Virginia nursing homes is provided. It demonstrates that understaffing is a choice remarkably popular among the out-of-state nursing home chains that largely pay Ms. Hewett’s salary and help fund Del. Willet’s campaign. It also shows how Medicare and Medicaid money go in the front door and out the back:

• Understaffing is clearly demonstrated to be a component of some business models. Staffing regulations will not change their behavior. Only aggressive sanctions for violating those standards will. The industry will argue and write checks for weak regulations. It has proposed sanction rules that demonstrate immunity to embarrassment.
• Understaffing naturally leads to unsafe conditions and the bad inspection results shown.
• Nursing facilities self-report patient needs for medical and activities of daily living. Some chain facilities consistently report that their residents, on average, are far more in need of medical and activities-of-daily-living assistance than the state or national averages. That results in higher reimbursements by Medicare and Medicaid.
• The facilities in the worst chains are much more crowded than the average Virginia nursing home, which, in turn, is far more crowded than the average American nursing home because of COPN.
• Chronic understaffing and high rates of worker turnover make it difficult for people with disabilities and older adults to have access to high-quality services. Take a look at the turnover rates in some.

This author will submit the evidence and commentary above to the Commission, attend the public sessions, and offer to testify.

The Commission

They have a seven-person staff with four analysts.

Facts on staffing

The 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report, The National Imperative to Improve Nursing Home Quality, Honoring Our Commitments to Residents, Families, and Staff, called for urgent reform to the U.S. nursing home system. This author, with no disrespect to the staff of the Virginia Commission, will defer to those worthies as the experts Del. Willet seeks.

From a section Regulations for Nurse Staffing,

In 2001, CMS conducted a large-scale study to identify appropriate nurse staffing ratios in nursing homes (Feuerberg, 2001; Harrington et al., 2020). The resulting report concluded that a “range of serious problems including malnutrition, dehydration, pressure sores, abuse and neglect . . . have pointed to nurse staffing as a potential root cause” (Feuerberg, 2001, p. 1). In addition to the numbers of staff in nursing homes being insufficient to meet the needs of residents, the CMS report identified several other staffing-related issues that contributed to poor quality in nursing homes, including high staff turnover and low retention, inadequate expenditures on nurse staffing, needs related to staff training/competencies, and ineffective or inadequate management and supervision (Feuerberg, 2001). The report also identified staffing thresholds below which residents were at risk for serious quality-of-care issues (Table 5-3).

From NASEM’s 2022 Workforce Recommendation: Update Staffing Standards and Expertise.

Despite persistent calls for increased staffing levels in nursing homes, the same federal regulations have been in place for decades. These standards do not reflect the complex needs of today’s nursing home residents.

The Centers for Medicare & Medicaid Services (CMS) should require a minimum of 24/7 on-site, direct-care, registered nurse (RN) coverage; a full-time social worker; and an infection prevention and control specialist at a level sufficient to meet the needs of the nursing home. Research to identify and rigorously test specific minimum and optimum staffing standards for all direct-care staff is needed to inform future staffing requirements …

CMS in 2024, after extensive consultation with “stakeholders”, established the following direct care standards:

• 3.48 HPRD total nurse staffing,
• 0.55 HPRD registered nurse staffing,
• 2.45 HPRD nurse aide staffing, and
• an RN on duty 24/7/365.

CMS thus reduced the recommended standard for total nursing HPRD, set at 4.1 in its 2001 report, to 3.48, perhaps in unspoken hope for grace from the industry.

Bottom line

The whole Joint Commission on Healthcare exercise appears fundamentally unserious.

• The Virginia Health Care Association wants 3.08 HPRD. Have no question, the nursing home industry lobby intends to buy low standards, whatever the price. The Chairman of the Commission has accepted a down payment.
• Asking the Commission’s 4-person research staff to redo the research work of the National Academies and CMS, and to develop standards other than those that those organizations have proposed, is playing political games with the health and safety of Virginians who cannot care for themselves.
• The law did not instruct the Commission to assess the elephant in the room, the subversion of standards by chains.

Here’s hoping they surprise us.