Category Archives: Health Care

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

Past Time for Serious Sanctions for the Commonwealth’s Worst Nursing Homes

by James C. Sherlock

Effective May 1 of this year, Karen Shelton M.D. became Virginia’s Health Commissioner. Dr. Shelton is now the licensor and regulator of Virginia’s nursing homes.

By law, state-licensed nursing homes must comply with federal and state laws and standards. By regulation, the Health Commissioner “may impose such administrative sanctions or take such actions as are appropriate for violation of any of the standards or statutes or for abuse or neglect of persons in care.”

It is time.

I hope that she will pose a challenge to her Office of Licensure and Certification (OLC), of which I am a public admirer, that goes something like this.

Too many Virginia nursing homes are measured objectively by CMS (the Centers for Medicare/Medicaid Services) to be dangerous to the health and welfare of their patients through a combination of:

  • inspections that we ourselves conduct;
  • staffing measures linked to payroll data; and
  • medical quality measures from federal records.

Many have been that way for a very long time.

Current staffing far below CMS requirements seems to indicate that too many have no apparent path to improvement.

Come and see me in a couple of weeks with a list of the absolute worst of them.

And tell me why I should not shut them down to let the rest know that there are minimum standards beneath which they will not be permitted to operate in Virginia.

And one more thing.

Please let me know if there are organizations or individuals, current or recent, whose facilities have appeared regularly enough with the lowest staffing rating to indicate that understaffing may constitute a business model rather than a local exigency.

That too will not be tolerated.

We will take on those challenges here as if they are our own.

This article will identify the absolute worst of the facilities, using government records. The next will look at understaffing trends among owners. Continue reading

No Clarity In This Process

by Dick Hall-Sizemore

Here is another example of the utter inanity of this country’s medical care system and its financing.

First, some background.  I am covered by Medicare.  I also have a Medicare supplement insurance policy issued by the Commonwealth of Virginia for retirees, administered by Anthem. (Good deal, by the way.)  I chose to include the vision and dental coverage on the Anthem policy.

Like almost everyone my age, I have developed cataracts.  A couple of years ago, an ophthalmologist told me that I qualified for cataract surgery, but that the cataracts had not progressed to the point that such surgery was highly recommended.  I chose to put it off.

Today, I went in for my annual eye exam.  As I was checking in, the staff at the Virginia Eye Institute (VEI) went to great lengths to explain that a refraction (the process of determining whether I need the prescription of my glasses changed) was not covered by insurance and that I would be responsible for the $70 if I chose refraction.  I even had to sign a form acknowledging that I had been informed of this. Continue reading

Virginia’s Best Nursing Facilities

by James C. Sherlock

This is part 4 of a series on nursing homes in Virginia. Part 1 here Part 2 here, Part 3 here. curates and publishes a system of nursing home assessments that is outstanding in both design and execution.

As discussed in earlier parts of this series, Virginia has far more bad nursing facilities than it should, but the Commonwealth also has more than its share of outstanding ones.

Fifty-two of 289 are rated five stars by CMS. Only 10% of the nation’s nursing homes achieve that rating. Eighteen percent of Virginia’s.

We’ll look at those best-of-breed facilities. Continue reading

Virginia Nursing Home Regulations and Inspections – A Strategic Improvement Recommendation

By James C. Sherlock

Those who read this blog know that Virginia has far more than its share of bad nursing homes. They just do not know what can or should be done about it.

This third in a current series on Virginia nursing homes will take on a problem that is self-inflicted – the state’s nursing home regulatory structure.

Virginia’s nursing home regulations, upon which Virginia licensing inspections are based, are promulgated by the Board of Health.  They are at best redundant to federal requirements.

At worst they are different than federal standards, with no discernible gain in nursing home quality.  Operators follow the federal rules anyway, because they are almost inevitably stricter than those of the state.

Virginia can improve its nursing home regulations by conforming them precisely to federal regulations.  State law already requires them to be in “substantial conformity.”

This change, if accompanied by the combining of federal and state inspections which it would enable, would make everybody happy.  It would also go a long way towards fixing the staffing problems at Virginia’s inspection agency by reducing significantly their required efforts.

Continue reading

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. Continue reading

No New Law or Regulation is Needed for VDH to Sanction Bad Nursing Homes

By James C. Sherlock

This is Part 2 of this series.  Part 1 is here.

I will offer here a deeper sense of Virginia’s bad nursing homes.  And of the historic lack of adequate regulation by the state.

Start with the fact that even the worst of them are still open.

Centers for Medicare & Medicaid Services (CMS) conduct and update at least quarterly a system of nursing home (and other facilities) assessments that is worthy of your trust.  I am cautious with all things government, but it has earned mine.

Nationally, 20% of nursing homes are rated one star overall by CMS.  In Virginia, 34% of nursing homes have that rating.

Don’t be mollified by the official designation of such facilities as “well below average.”  Many are places persons as vulnerable as nursing home residents should not be permitted to reside.

We are disgraced by having let that happen.   Virginians, through our state government, need to assure it does not continue.

Continue reading

Scandal in Plain Sight – Virginia’s Failed Regulation of Law-Avoiding Nursing Home Owners

by James C. Sherlock

One of the most important and heart-wrenching decisions families make for their elderly loved ones is whether they are able to keep them in their homes as they get older and sicker.

Sometimes that is not feasible for a long list of reasons in each case.

More than 30,000 Virginians live in nursing homes.

Both the federal government and Virginia regulate them.  The Virginia Department of Health, for both the Commonwealth and the federal government, inspects.

We should be able to expect patients to receive at least basic standards of care. A high percentage in Virginia have not .

In a five-star system, the Centers for Medicare and Medicaid Services (CMS) rates 98 of Virginia’s 289 nursing homes at one star – defined as much below average. More than a third.

Nationwide, only the worst 20 percent receive a one-star rating.

The last time I reported, in October of 2021, those figures were 54 one-star facilities out of 288. Nineteen percent.  So some of our nursing homes have gotten precipitously worse.

The ratings are backward-looking a couple of years, so the measured declines discussed here did not start recently.   By definition of the way that Medicare compiles records and assigns scores, some have been bad for a long time.

People have suffered and died from the lack of proper care and effective oversight. Continue reading

Sentara Does a Very Good Thing

Courtesy Sentara

by James C. Sherlock

Sentara brass will not believe that I wrote that headline. We have a history.

But right is right.

A Sentara mobile care unit will start June 1 to provide primary care service two days a week in two separate locations in Petersburg.

The people of Petersburg desperately need it. That city is rated the Commonwealth’s least healthy jurisdiction.

Without good primary care, a health system never has a chance.

The partners in providing the mobile unit are Sentara, Potomac Health Foundation and Sentara Northern Virginia Medical Center Auxiliary.

Congratulations to all of them. Continue reading