Category Archives: Health Care

How Did VCU Miss the Red Flags?


by Jon Baliles

The unravelling saga of a failed development proposal downtown a block from City Hall that was supposed to rise out of the ashes of the failed Navy Hill project is still smoldering. The failed deal has come with a price tag of about $80 million so far (and growing) for VCU Health. They were supposed to be the main tenant of the project and, by all accounts, approved and signed a deal in July 2021 in which VCU accepted heavily one-sided terms that have become so expensive it could still ripple throughout the city, the university, and the state.

Eric Kolenich has peeled back the latest layer of the onion in an eye-popping article in the Times-Dispatch this week, with emails that revealed grave concerns with the deal that would leave VCU Health holding the bag, and also emails that showed more concern to close the deal than what was in it. The emails show both bad communication and miscommunication among those at top levels of VCU’s administration at both the Monroe Park campus and the medical campus. They were sent in a flurry in the weeks leading up to VCU inking and approving the deal, and ignored warnings that were raised in favor of a closer analysis or alternative parachutes that would offer a way out.

After the Navy Hill project failed in early 2020, Capital City Partners, the developers who led that attempt, returned to the city with a proposal for a development for the city’s dilapidated old Public Safety Building at 500 N. 10th Street (aka the Clay Street Project because it is at 10th & Clay Streets). The proposal was for a 17-20 story building that would be leased by VCU Health for office use. They would pay $650 million in rent over 25 years that would produce close to $60 million in tax revenue for the city.

VCU would have to pay rent starting in 2024, whether or not the building was completed, as well as pay for repairs and maintenance. If the project faced cost overruns, VCU would also be on the hook for those.  And strangely, since it was office space, it would not generate any revenue for VCU Health like other facilities they had recently built (e.g. the Children’s Hospital). Continue reading

Lost Kids of Southwest Virginia

Kingsolver, Barbara. Demon Copperhead.  Harper, 2022

 A review by Dick Hall-Sizemore

Barbara Kingsolver is an award-winning author who lives on a farm in Washington County, Virginia. Her latest novel, Demon Copperhead, is what she calls her “great Appalachian novel.” It was awarded a Pulitzer Prize for Fiction this year.

Kingsolver grew up in Appalachia, in eastern Kentucky. After graduating from college in Indiana, she spent several years backpacking around Europe. Upon returning to the United States, she wanted to see the West, and ended up in Tucson. She says that she did not go to Arizona with the idea of settling there, but life happens. During her two decades there, she published several well-received novels. She began to feel the pull of Appalachia and, thus, several years ago, she and her family moved to a farm in Washington County. Continue reading

Nurse Staffing in Virginia Nursing Homes in July Ranked 49th in the Nation

by James C. Sherlock

The Centers for Medicare & Medicaid Services (CMS) has released its national nursing home quality data for July.

It provides summaries of nursing home performance for each state, the District of Columbia and three U.S. territories.

I sorted it for Reported Total Nurse Staffing Per Resident Per Day. I did that because Virginia’s lead nursing home lobbyist in January insisted, on video, to a hearing of an always-compliant General Assembly that the Commonwealth’s nursing homes be judged by that metric.

In July, our nursing homes ranked 49th by their own preferred total nurse staffing measure. Nurse shortages are nationwide, so that fact cannot explain it.

Those same nursing homes in those same data ranked 45th in total nurse turnover at 57.5% annually. Some of the worst individual Virginia nursing homes experience nearly 100% nursing turnover annually.

That creates a vicious cycle.

  • Virginia has too many nursing homes that are understaffed, some by design;
  • Nurses quite naturally don’t like to work in them and, with many job options, will not remain in such places;
  • When staffing falls, nurses know it from CMS data or reputation and won’t take a job where they will be overworked and unable to provide optimum care to patients;
  • The understaffed nursing homes get worse.

Continue reading

New CMS Hospital Quality Rankings – Virginia Facilities Ranked Exceptionally High

by James C. Sherlock

UVa Hospital

The Centers for Medicare & Medicaid Services (CMS) on Wednesday released its latest annual hospital quality rankings .

Only 10.4% of the rated hospitals in the country were awarded the top ranking of five stars.  Of Virginia’s 74 rated hospitals, 13 received that top ranking. Almost 18%.

Nationally, 28% received one of the top two rankings.  In Virginia, 58%.

As a whole, Virginians are exceptionally well served.

By Hospital.  I have taken Virginias hospitals from the new national list and sorted them descending by star-ranking, 5 stars though 1 star.  The results are here.  

The footnote dictionary is here.  For the column header dictionary, see here.

By Hospital System.  Categorized by system and with computed system hospital averages, the system ranking is here, sorted, like the individual hospitals, descending from best to worst.

By Region.  See here.  Northern Virginia, with all of its hospitals 5- and 4-Star rated, may be the only region of its size in the country that can make that claim.

Regional wealth or poverty, and the attractiveness of the location to staff and management still matter.  Especially management.

The new rankings show significant changes.  We’ll take a look.

Continue reading

Nursing Homes – What Could Go Wrong?

Mt. Vernon Healthcare Center Alexandria

by James C. Sherlock

I have written a lot recently about staffing shortages in Virginia nursing homes and the Commonwealth’s national ranking near the bottom of the states for staffing measures.

It is appropriate to ask why that matters.

Federal analyses of Centers for Medicare & Medicaid Services (CMS) data offer the answer.

In proposing to adopt the Total Nursing Hours per Resident Day Staffing (Total Nurse Staffing) measure for the FY 2026 program year and subsequent years, the rule-makers offered this:

Staffing is a crucial component of quality care for nursing home residents. Numerous studies have explored the relationship between nursing home staffing levels and quality of care. The findings and methods of these studies have varied, but most have found a strong, positive relationship between staffing and quality outcomes.

Specifically, studies have shown an association between nurse staffing levels and hospitalizations, pressure ulcers, weight loss, functional status, and survey deficiencies, among other quality and clinical outcomes.

The strongest relationships have been identified for registered nurse (RN) staffing; several studies have found that higher RN staffing is associated with better care quality. We recognize that the relationship between nurse staffing and quality of care is multi-faceted, with elements such as staff turnover playing a critical role.

Remember, the surveys are conducted both for CMS certification and Virginia licensing by the Office of Licensure and Certification (OLC) of the Virginia Department of Health.

I have always found that office to be staffed by exemplary public servants, even while there have never been enough of them.

But we’ll get specific about Virginia nursing homes and survey deficiencies as the answer to the question:

“What could go wrong?”

Continue reading

Staffing Has Collapsed in Many Virginia Nursing Homes, Creating a Health Crisis for Our Most Vulnerable Citizens

by James C. Sherlock

I am seldom surprised by Virginia’s nursing home staffing problems, but new government data show no progress on staffing since October of last year.

Data from the Centers for Medicare & Medicaid Services show that the number of significantly understaffed facilities has not budged in seven months.

The numbers don’t lie.

And it undeniably represents a health crisis for our most vulnerable citizens.

The questions are: what are the facility operators and the Virginia Department of Health going to do about it? Continue reading

Understaffed Nursing Homes and the False Claims Act

by James C. Sherlock

Nursing home operators, paid by government insurance programs on a per diem basis for caring for their patients, make higher profits if they understaff than otherwise.

The less staff they have, the higher their operating margins.

The federal government, with much experience in such situations, tries to offset those incentives with disincentives. It thinks, reasonably, that patients should actually receive the care that is paid for with government insurance funds.

In Virginia, some senior members of the health committees of the General Assembly are in love with our nursing home operators, offering legislation as gifts. That love is requited in the form of unlimited campaign contributions from the operators.

Touching story.

This being Virginia, that is legal. And too common.

However, help for patients is available and very active on another front: fraud charges brought by states and the Justice Department in federal court.

The unanimous Supreme Court opinion in Universal Health Servs., Inc. v. United States 136 S. Ct. 1989 (2016) • 195 L. Ed. 2d 348 Decided Jun 16, 2016 provided precedent for such filings under the False Claims Act.

The Court validated the government’s theory of law that a provider can be guilty of making a false claim based on the underlying representation that the care provided complies with the government Conditions of Participation.

Grossly understaffed nursing homes can be guilty of criminal or civil false claims or both by accepting payments for services which they do not provide or provide inadequately.

Both state and federal governments know exactly who those understaffed nursing homes are and have the payroll-based data to prove that some could not have provided it.

And they are taking the worst offenders to court. Continue reading

An Utter (and Videotaped) Disgrace of the Virginia General Assembly

by James C. Sherlock

Scott Johnson at the podium on Jan 17, 2023 testifying before the House Committee on Health, Welfare and Institutions.

Whatever the Virginia Health Care Association (VHCA), the state’s nursing home lobbying organization, pays its General Counsel, Scott Johnson, it is not enough.

He has been representing them for 20 years, and he owns the General Assembly.

This is going to sound boring as I frame the background that is the subject of the hearing. But I feel I must try to explain the complexities to make what happened in the hearing understandable.

But I promise the hearing itself is not boring. There are heroes, heroines and villains.

That hearing was a thoroughgoing disgrace to the General Assembly of Virginia. Members are seen clearly to surrender their authority, their duties, and their personal dignity to an industry they are elected to oversee.

It was videotaped for posterity.

It represents the “Virginia Way.” a product of unlimited campaign donations. It is reprehensible.

The law passed through this process must be repealed in its entirety. Continue reading

Corruption, Ignorance Turn Deadly in the General Assembly

by James C. Sherlock

Virginia Department of Health inspectors, on page 11 of 66 of a statement of deficiencies dated June 21, 2021, wrote of a gut-wrenching discovery.

They found an incontinent patient at Autumn Care of Suffolk, a stroke victim unable to talk, tied to her bed by a staffer. She was terrified and humiliated.

The investigation resulted in lots of finger pointing but failed to pinpoint responsibility. Adult Protective Services found that the patient had been abused. The facility promised better training.

Autumn Care of Suffolk last quarter offered 17 minutes of registered nurse (RN) time per resident per weekday vs. a national average of 39 minutes. It provided five minutes of RN staffing per resident per day on weekends vs. a 26-minute national average. It is currently open and accepting new patients.

This article is for that poor woman.

And it is for the nurses, heroines and heroes of the pandemic, who consider nursing a vocation as well as a job. There was a shortage of RNs going into the pandemic. It is worse now because of burnout. Continue reading

Nurse Staffing Laws Bringing Big Changes are On the Horizon

Sentara Halifax Regional Hospital, South Boston

by James C. Sherlock

In my lengthy series on Virginia’s nursing homes, I pointed out that many of them are understaffed with nurses, RNs in particular.

I also pointed to a nationwide nurse shortage, due in part to burnout, that the training pipelines are not poised to fill.

New York, Pennsylvania and Oregon are poised to mandate by law minimum staffing for hospitals and skilled nursing facilities to address both patient safety and burnout.

On June 28, the Pennsylvania House, in a bipartisan vote, passed a bill that declared:

(1) Health care services are becoming more complex, and it is increasingly difficult for patients to access integrated services. Continue reading

Private Equity in Medicine

To add to those revealed in  James Sherlock’s excellent posts about nursing homes and the health care industry generally, here is another culprit–private equity firms.  They buy up medical practices in an area, creating great bargaining power with insurance companies, and begin raising prices.  The fight is between giant, merged insurance companies and giant, merged medical practices.  The losers are patients and the winners are the private investors.

Today’s Washington Post has a long article describing how this happened with anesthesia practices in the Denver area.  The company, U.S. Anesthesia Partners, which calls itself a physician-owned company, was, in reality, created by the private equity firm, Welsh, Carson, Anderson & Stowe, which owns 55 percent of the stock.

Nursing Shortages Require Better Oversight of Virginia Nursing Homes – Part Two – State Action Required

by James C. Sherlock

Patterns of understaffing, medical harm and abuse in nursing homes are traceable:

  • in some cases to a business model of understaffing to increase profits. Federal fines are built into the business models of the bad actors. Some of the worst post double-digit annual operating margins;
  • in some to other systemic chain-wide issues, perhaps financial instability; and
  • in yet others to local management incompetence and other site-specific issues.

Regardless of the reason, Virginia regulators and law enforcement agencies must execute the roles they are legally charged to perform.

State sanctions must be levied.

  • The Health Commissioner can block the admission of new patients until staff levels support them or shut down those facilities that do not meet standards over a long period of time;
  • The Department of Medical Assistance Services (DMAS) can suspend or halt Medicaid payments;
  • The Attorney General can prosecute for civil or criminal violations.

Enforcement will result in fewer, but better and safer options. Continue reading

Nursing Shortages Require Better Oversight of Virginia Nursing Homes – Part One – The Problem

By James C Sherlock

We have some great nursing facilities in Virginia. We also have far more than our share of bad ones.

Virginia has a decision to make about the latter.

The federal government sets standards for those that are paid with federal funds.  It both levies fines and denies payments as it feels appropriate.

But more direct action to assure quality of and safety in nursing homes is left to the states, who both license and regulate them.

There are simply not enough nurses nationwide or in Virginia to staff all of the nursing homes currently operating.  And that shortage is not temporary.

The decision Virginia needs to make is straightforward:

  • do we want to keep open to new patients the 289 certified nursing facilities currently in operation; or
  • do we want to ensure patient safety.

We cannot have both.

The nursing shortage cannot be a reason for government to leave open to new patients grossly understaffed nursing homes.  If that understaffing is sufficiently chronic, some must be closed.

Among the bad facilities, some owners are scoundrels.  Others are just not able to get it done.  Better enforcement will reduce the number of both.

Actions must be taken to assure that when citizens need a nursing home, the state license can be trusted as a sign that basic standards are maintained.

That they will be safe.

Continue reading

Profound Registered Nurse Shortages in a Virginia Beach Nursing Home

By James C. Sherlock

Registered nurses (RNs) both supervise medical treatment and are the primary medical care providers in nursing homes.

Physicians are on call but generally are not present.

One Virginia nursing home is currently advertising:

RN’s Now hiring All Shifts! Pick your shift.

Perhaps not good news for those patients.

Some of the worst nursing homes are just bad places to work.  Others don’t pay their nurses enough.

Some both.

I will describe with Centers for Medicare & Medicaid Services (CMS) information a Virginia Beach nursing home that:

  • is grossly understaffed; and
  • has been cited in its most recent inspection both for abuse of patients and for failure to provide appropriate treatment and care.

Yet it is open and soliciting new residents.

Continue reading

Predatory Virginia Nursing Home Owners

by James C. Sherlock

Merriam Webster:

Pred*a*tor: (noun) one who injures or exploits others for personal gain or profit.

The most medically vulnerable of us reside in skilled nursing facilities (SNF).

Nobody plans to be there, but that is where about thirty thousand Virginians find themselves at any one time. People who are moved from hospitals to save money for the insurers but are too sick or injured to go home yet.  

They are supposed to get the skilled nursing the name suggests. Many don’t.

Most are covered by Medicare. The rest by Medicaid or private insurance. It could be any one of us tomorrow.

These patients are at risk by design in some of these SNF’s. Put in danger by a perverted business model, a model that shows that returns can be juiced into double digits by stripping staff. The facilities can then be flipped in a couple of years at a profit based upon increased cash flows.

We will track their investments using government data. We will see a ritual, system-wide understaffing.  We will also see that the government accumulated and publishes staffing data but there is no evidence they use it for anything.

There are nursing homes in Virginia, for example, that provide less than 30% of the registered nurse hours per patient per day that CMS assesses they require.  Weekend statistics are worse. Nothing happens.

Today there are large systems not one of which is staffed to CMS norms.

There are real people who are harmed by those calculated violations.  Exceptionally vulnerable people are regularly denied at least their dignity, often their health and sometimes their lives.

The owners injure and exploit patients for personal gain or profit.

They are predators. Continue reading