A Supplement to James Sherlock’s Post

by Dick Hall-Sizemore

James Sherlock has done yeoman’s work on this blog with his pointing out the failure of state government to adequately regulate the nursing homes in the Commonwealth. I commend him for his perseverance on this issue.

In doing some research on the budget issues related to this topic, I encountered enough additional information to warrant a separate article, rather than a comment. Therefore, this article should be regarded as a supplement to the recent articles posted by Jim. It also provides me the opportunity to acknowledge that I unfairly criticized the House Republican majority in a comment to one of his earlier posts.

The prior administration and the current General Assembly have taken steps to create a carrot-and-stick approach to increasing the staffing in nursing homes.  In the 2022-2024 biennial budget proposal submitted to the General Assembly just before he left office, Governor Northam included language directing the Department of Medical Assistance Services (DMAS) to work with the nursing home industry to “develop a unified, value-based purchasing (VBP) program that includes enhanced funding for facilities that meet or exceed performance and/or improvement thresholds… Nursing facility performance evaluation under the program shall prioritize maintenance of adequate staffing levels and avoidance of negative care events, such as hospital admissions and emergency department visits.” The General Assembly passed the budget bill with no change in this wording.

Although Northam did not include any funding for this program in his proposed budget, the General Assembly included funding in the final Appropriation Act–$12.5 million for FY 2023 and $25 million for FY 2024 in general fund appropriation and comparable appropriations for federal funds.

The 2023 General Assembly enacted HB 1446, which, for the first time, places a nursing home staffing standard in the Code of Virginia. The bill, which passed both houses overwhelmingly, was introduced by Del. Robert Orrock (R-Caroline). (It may have been introduced at the request of the administration, but there is no readily available way to determine whether that was the case.)

The enacted legislation requires each nursing facility eligible to participate in the VBP program “to provide at least 3.08 hours of case mix-adjusted total nurse staffing hours per resident per day on average.”  Furthermore, the legislation provides the Commissioner of Health with detailed authorization to levy sanctions against facilities that do not comply with the regulations developed regarding the standards.

The levying of sanctions is contingent upon the provision of the state’s share of the costs of implementing the act. The budget amendments proposed by the House Appropriations Committee included $31.5 million in general fund appropriation and an equal amount of federal appropriation in Fy 2024 to implement HB 1446.  That funding would be in addition to the $25 million provided by the 2022 General Assembly. Of course, that additional $31.5 million is caught up in the budget impasse.

The other aspect of this issue that Jim has stressed has been the shortage of staffing in the Department of Health’s (DOH) Office of Licensure and Certification (OLC). According to some DOH base documents, approximately 80 percent of the funding for OLC comes from the federal government. The federal government provides 75 percent of the funds for all state Medicaid survey and certification program costs. Apparently, the attitude of DOH, not uncommon in state government, is that the agency will provide the minimum state funds needed to match available federal funding. During the past administration and the current one, DOH has not requested additional inspection positions, the governor has not proposed them in his submitted budgets, and the General Assembly has not offered up any funding for additional positions.

Before advocating for additional inspection positions, there are several questions that should be asked and answered. First, what is the turnover/vacancy rate for these positions? If it is common for several positions to be constantly vacant, then it does not make much sense to give the agency more money for more positions when it cannot keep filled the positions it already has. If the turnover/vacancy rate is significant, the next question is: Why? If the agency is losing inspection staff to other agencies or the private sector, is it a case of the DOH salaries being too low or is the cause something more intangible, such as working conditions or office morale? If it is a matter of salaries, it would probably be more effective in the long run to provide additional funds, not for additional positions, but for increases in the salaries of the inspection staff to aid in retention and recruitment.