Update: Virginia COVID-19 Testing and Nursing Home Data

by James C. Sherlock

I update here the continuing scandals in Virginia nursing home understaffing and COVID-19 testing.

In a quarterly update, the percentage of understaffed nursing homes and the Virginia’s relative standing among the states and D.C. in that statistic every quarter are posted on Medicare Nursing Home Compare. Here are the data from 03/30/2020:

  • Fifty-one percent of Virginia nursing homes are understaffed (below average or much below average).
  • Virginia ranks 45th worst of 51 among states and D.C. in percentage of nursing homes understaffed.
  • Forty-two Virginia nursing homes are rated one star (much below average)

I will update Virginia COVID-19 testing data weekly.

  • Virginia testing per million persons ranks 50th of 51 among states and D.C. (Only Kentucky is worse).  Source covidtracking.com uses only official state government data and is updated daily. This ranking is from 04/24/2020
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19 responses to “Update: Virginia COVID-19 Testing and Nursing Home Data

  1. “– Virginia Testing per million persons – ranks 50 of 51 among states and D.C. (KY worse).”

    But not to worry, University of Virginia fresh off its Coved-19 testing debacle, UVA now has a shiny new politically corrected brand, according to its propaganda machine, namely:

    “United by our uncompromising commitment to excellence, Cavaliers know that with each day comes an opportunity to get stronger, faster and smarter. In this spirit, we partnered with Nike to evolve the face of Virginia Athletics. Using iconic elements from the brand, we crafted new marks that articulate the strength, diversity and ethos of our program and speak to a new generation of Hoos.”

    For more in brazing UVA colors see:

    • James Wyatt Whitehead V

      The new Cavalier logo is just silly. The Cavalier doesn’t show his face. Head bowed down. All you see is the top of a big hat. It looks like a cheap Andy Warhol knockoff. I wonder what VPI is going to do with the Fighting Gobbler or Hokie Bird?

  2. “Understaffed” could be a relative term. In fact, it is a comparison to the national average. More relevant would be the number or percentage of nursing homes that habitually (regularly, chronically?) fail to meet the minimum state staffing standards.

    Virginia has long “prided” itself in having some of the lowest Medicaid reimbursement rates in the country. That could have well contributed to Virginia’s nursing homes being staffed at levels below the national average.

  3. These metrics that CMS has on staffing – where does CMS get them?

    If Medicaid is paying – is the amount of reimbursement pretty much fixed and if the Nursing home increases staffing – they won’t get any more from Medicaid?

    I know CMS can stop Medicare/Medicaid from paying a nursing home that has “failed”. Can VDH/Virginia do the same – i.e. stop Medicaid payments for the patients in that home?

    If they do that, what happens next?

    What is the process of moving the residents to other nursing homes? Do other homes have to take them no matter what? Can they refuse to take them? If a nursing home with more/better staffing will take them but it charges more than Medicaid reimbursement what happens?

    • Good questions.
      Every nursing home certified by Medicare and Medicaid is required by law to submit quarterly their payroll data from which the numbers of hours of each classification of employee are developed. Those numbers are then compared to the national average for the classification of facility (nursing home or skilled nursing facility or both in different wings/floors of the same facility) adjusted for the severity of the disabilities of the patients in each classification. The adjusted numbers then represent apples to apples for comparison. So if you find a nursing home with a one-star rating, you do not need to inquire about the details, they are all factored into the rating. If you think about it, the ratings would be useless if they needed to be interpreted.
      In answer to your second question, VDH actually metes out punishments with the delegated authority of CMS. I have published the list of available punishments in a couple of previous posts. VDH is charged with choosing the most effective. If patients are to be transferred to another facility – home care, another nursing home, a long term care hospital or an acute care hospital depending on the status of the patient, the transfers are made by ambulance.
      As but one example, in the theoretical case of a facility that does not have enough nurses, especially registered nurses, a remedy might be to move some number of the sickest of the patients, both reducing the numbers of patients and the ones that need the most care measured in minutes per day. If the nursing and other staff remain stable and enough of the sickest patients are moved, then the nursing home can devote an acceptable amount of care time to those remaining.
      Sufficient data are available for VDH to make such decisions. I just think that they do not do it nearly often enough. That is the reason more than half of Virginia’s nursing homes are understaffed.

  4. This continues to be a terrific series.

    You may have answered this but, if not, do you have information on the level of aggressiveness of other states in employing remedial actions. Do they actually move patients or close facilities or use these measures which Virginia apparently does not?

    • This will sound like a cop out, but some do and some don’t. 41 states have laws that specify specific minimum levels of staffing in nursing homes. Virginia is not one of them. So all of the calls made by VDH on levying penalties are subjective. I don’t have data on the relative aggressiveness of states in remedial actions. But inevitably the aggressiveness of regulators is directly proportional to the willingness of the facilities to maintain sufficient staff. When I built a spreadsheet of facilities in 50 states and D.C., there were nine states and D.C. that had less than 10% of their nursing homes understaffed, and eight states, including Virginia, with more than half understaffed, topped by Texas and Louisiana each with more than 80% understaffed.
      Another example of the Virginia way. Ask Tommy East, the nursing home industry member of the Virginia Board of Health appointed by two consecutive Governors. In Virginia politics, money talks, and the occupants of nursing homes don’t tend to be big contributors.

      • Now I understand. The key element in the response above is that Virginia does not specify a minimum level of staffing in nursing homes. I assumed it did (that was the basis for my comment above.) The relevant VDH regulation states: “The nursing facility shall provide qualified nurses and certified nurse aides on all shifts, seven days per week, in sufficient number to meet the assessed nursing care needs of all residents.”

        The standard “sufficient number to meet the need” is entirely subjective and very hard to regulate. (That was probably the objective of the nursing home industry.) Therefore, VDH has no legal authority to close down a nursing home because its staffing is below the national average. It has to find some other reason. Most of the regulations deal with procedures. If a nursing home is found deficient, it can promise to do better and remain in business.

        Larry asks if Medicaid reimbursement would increase if a nursing home increased its staff. It wouldn’t. Medicaid reimbursement is tied to the patient. So, a nursing home gets money for each patient it houses. It can increase the number of patients, put them three in a room, without increasing staffing, and get more Medicaid money.

        Nursing homes are not required to accept Medicaid patients. I would bet that those who do not, those with patients that have the resources or other, better insurance, are better staffed. The nursing home industry will argue that Virginia’s relatively low Medicaid rates prevent it from staffing facilities which accept Medicaid patients better. The Commonwealth is in the process of increasing Medicaid rates for nursing homes. Along with more money should come better staffing.

        We have laws and regulations setting minimum staffing standards for schools and day care centers. We should show the same regard for the state’s older, and just as vulnerable, citizens.

        The most effective way of getting this changed is through legislation passed by the General Assembly directing the Board of Health to amend its nursing home regulations to include minimum staffing standards.

  5. Yes. The thing is that nursing homes are private sector businesses and one might presume (perhaps wrongly) that they do have the right to decide what business they will accept and what prices to charge and that higher price delivers more staff than some nursing homes might for less money or medicaid reimbursement-only.

    So, does the Govt require other nursing homes to take patients of a facility that the state closed down and less money than they normally charge?

    and Thank You Jim for sharing your knowledge which is extensive.

    • Just because a Medicaid certified nursing home has empty beds, it need not accept new patients. And it would do no good to further burden another understaffed nursing home. But VDH has enough up-to-date data to thread that needle if they wanted to. Nursing homes are in business to make money, and if they have beds and staff to accept new patients, they will. The current situation is of course the worst case scenario, but the reluctance on the part of VDH to act didn’t start last month.

  6. I don’t know for sure but I’d speculate that nursing homes are a little like doctors in that they cannot survive financially solely on medicaid revenues, that they need some level of paying customers whose reimbursements are better than medicaid.

    We’ve heard cited on these pages that hospitals have the same problem – that medicaid reimbursement is insufficient to pay costs so hospitals not only rely on people with better insurance,but they actually cost-shift from the higher paying folks to cover their medicaid and uncompensated care losses.

    So… is what is happening to nursing homes that are “free market”be the same thing to a COPN environment if the free-market competitors were required to take Medicaid reimbursement and some of them became so to-heavy with a high percentage of Medicaid that they’re have to cut corners on staffing and such to still make a profit?

    I presume that if the State (or Feds) would essentially shut down a facility that they would take responsibility to find new homes for people rather than cutting them lose to try to find their next home.

    But again – I do wonder if the State can FORCE other nursing homes to take such displaced residents or that other nursing homes could say “no” even if they have available beds but taking more Medicaid reimbursements would tip the scales on how much staffing could be provided – and still remain financially viable?

    My strong guess is that the nursing homes with one or two stars have lopsided numbers of Medicaid folks and the higher rated nursing homes especially on staffing have less medicaid patients.

    Thst State, as far as I know, does not “force” private sector Doctors to take Medicaid patients so I wonder, once again, if any given nursing home can refuse to take more Medicaid patients if they feel that each one they take actually costs more to care for than they receive in payments and they are forced into staffing changes that are not good for anyone.

    If that is true – and I do not know that it is – but if it is true and the State really cannot force other nursing homes to take displaced people, then one can understand why the State would be reluctant to close one down and prefer instead to work with them to improve – which, by the way, seems to be how CMS works also.

    The point of the ratings is to encourage the low performers to recognize that there are other nursing homes out there that do better so it is possible to do better – but does take more effort.

    I much appreciate the discussion that is more focused on the problems of nursing homes in general rather than trying to assign political blame.

    I still point out that there are more than 280 nursing homes in Virginia and if it is true that most all of them have staffing issues because VDH is lax in enforcement then, yes, something needs to change but I’m doubting that we’re going to do it in the middle of a pandemic because the risk of making things even worse is a definite possibility.

  7. Well, this just justifies an 80-year old knifing someone. Comparatively speaking, you’re safer and better fed in Mr. Hall-Sizemore’s prisons than CAPT Sherlock’s nursing homes — probably a more congenial ambiance, too.

  8. Wait! What?


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