Category Archives: Long Term Care and Nursing Homes

National Academy of Sciences Offers Superb Recommendations for Fixing Virginia’s Nursing Home Crisis

by James C. Sherlock

Sometimes, we need to listen.

I just finished the 806-page 2022 report The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff by the National Academy of Sciences (NAS). It is downloadable at the link.

That study and report were utterly professional and thorough, as scientific as you expect, remarkably staffed and bipartisan in recommendations.

I have compiled from Appendix D of that report those remedies recommended for execution by states and nursing homes. They deserve to be the centerpiece of Virginia law and regulation going forward.

All of them. Continue reading

The Virginia State Budget and the Rising Costs of Registered Nurses

by James C. Sherlock

I was asked yesterday by a reader about the relationship between nursing homes, rising registered nurse salaries and the new Virginia budget agreement.

Good questions. Virginia’s workforce includes nearly 70,000 registered nurses.

The state pays its workers, but it also pays its Medicaid share for private sector nurses. Pay for private sector workers is based upon market conditions. The market wage for registered nurses nationwide increased dramatically during COVID.

Perhaps the only good thing to come out of that mess was that registered nurses, of whom Virginia has 11% fewer than demand calculated by the federal Health Resources and Services Administration, got very large pay and bonus raises, and the new wage points appear to have stuck.

If the laws of economics work here, that will over time increase the number of nurses if we can educate and train them in the required numbers.

The latest figures from the Bureau of Labor Statistics for all states show that the median wage for an RN in Virginia was $79,700 a year. In Northern Virginia portion of the D.C. metro area, the median was $92,800.  The underlying data are a couple of years old.

Wages and bonuses can vary a lot among Virginia hospitals, nursing homes, home health agencies, nursing school staff and government employees, and are higher or lower depending on specialty. The private sector offers $10,000 to  $20,000 signing bonuses paid out after the first year.

Employers of course must pay payroll taxes and other expenses related to employees, and thus their costs will generally exceed $100,000 per RN.

Virginia RNs are still underpaid compared to national figures. The mean annual wage for America’s 3 million registered nurses in May was $89,010 compared to Virginia’s $79,900.

The federal Centers for Medicare/Medicaid Services, aware of some of the questionable business models of bad actors in the nursing home industry, published last week a proposed rule to both increase the minimum number of RNs in nursing facilities and to require all nursing facilities to reveal every year how much of the Medicare and Medicaid payouts go to salaries and related expenses.

So, Medicare and Medicaid costs will go up yet again. Continue reading

Virginia Has an Opportunity to Take the Lead in Nursing Home Technology Insertion to Improve Care with Existing Staff

by James C. Sherlock

A pending new federal rule defining strong nursing home staffing minimums has finally accomplished something that I thought unlikely in my lifetime.

It has in a single stroke aligned the interests of patients and their loved ones, nurses, nursing homes, state and federal governments, and taxpayers in finding ways to make existing nursing home staffs more efficient and effective.

That alignment brings the miracle of the loaves and fishes to mind.

It takes some explaining.

  1. The value of the new regulations to patients and loved ones and nurses is clear. Better quality of care for patients and better working conditions — less stress and better job satisfaction — for the nurses.
  2. The nursing homes and their lobbyists oppose the new rule, but it appears that it will happen. They face a significant shortage of registered nurses in Virginia and competition for nurses from hospitals with deeper pockets. So, they very much want to somehow reduce the new minimum federal requirements.
  3. The state and federal governments, and thus the taxpayers, will inevitably see demands for Medicare and Medicaid payment increases to pay for the new staff. So, it would benefit taxpayers and the national debt to reduce those ratios as long as the desired levels of care could be maintained.

One answer to address all of those interests is extensive automation of processes in which nurses are involved. Just some of the requirements:

  • Integrate electronic health records (EHR) and nurse support apps for real-time data entry on mobile devices;
  • Remotely pre-screen, prioritize and automate alert and alarm workflows;
  • Alert to medication administration requirements and help prevent medication errors;
  • Enable nurses to notify the appropriate responders to crises with one click on a mobile device.

Continue reading

Virginia’s Certificate of Public Need Program – A New Sheriff in Town

by James C. Sherlock

Everywhere counterproductive to competition, innovation and cost, Virginia’s Certificate of Public Need (COPN) program also has proven antithetical to quality and safety in nursing homes.

A thorough 2022 report by the National Academies of Sciences, Engineering and Medicine on improving nursing home quality had this to say about state Certificate of Need (CON) programs:

Certificate-of-need regulations and construction moratoria do not appear to have had their intended effect of holding down Medicaid nursing home spending; rather, these laws can discourage innovation and decrease access.

Certificate-of-need regulations may contribute to the perpetuation of larger nursing homes.

Despite the prominent role of nursing home oversight and regulation, the evidence base for its effectiveness in ensuring a minimum standard of quality is relatively modest.

The role of Virginia’s COPN program is as counterproductive to nursing home quality as is imaginable. Remember, COPN decisions happen before the state and federal regulators of the operations of nursing homes even get into the game.

Virginia’s COPN program is a statutory incumbent protection regime across all of its regulated targets. But it has gotten especially bad results with nursing homes, which by nearly every measure are among the worst in America.

In Virginia, the only realistic way to increase the size of a nursing facility is by COPN approval of the transfer of beds from one facility to another, often from one region of the state to another. Continue reading

New Virginia Nursing Home Law Appears to Violate Federal Statute

by James C. Sherlock

In addition to the General Assembly embarrassing themselves in the way they passed a law on nursing homes in this year’s session, they did it in an unseemly rush.

There was no pre-filing, a near-immediate and disgraceful floor “debate” led by the nursing industry’s lobbyist, and a rushed vote in the House Health, Welfare and Institutions Committee.  

A committee member in the House hearing asked for time to consider the bill. Her request was denied by the Chairman, who was the House patron of the bill. That was followed by a cursory review in the Senate Education and Health Committee before near-unanimous passage by both bodies.

Now it appears that the new state law they passed may violate the governing federal statute. Which, of course, state laws are not permitted to do under the supremacy clause. Continue reading

The Ongoing Tragedy of Virginia’s Nursing Homes

by James C. Sherlock

Virginia’s Health Commissioners have a job that is broad and deep in its responsibilities and authorities.By statute, appointees must be physicians.

Each is the chief executive of the Virginia Department of Health (VDH): a central office in Richmond and 35 local health districts.

By Virginia statutes and regulations, they are also the final decision authorities on such issues as the licensing of hospitals and nursing homes and all Certificate of Public Need decisions.

Nursing homes. To the point of this particular discussion, Health Commissioners have since at least 1989 possessed statutory (Code of Virginia § 32.1-135) and regulatory 12VAC5-371-90. Administrative sanctions authority to sanction Virginia nursing homes.

B. The 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. Such sanctions include:

  1. Restricting or prohibiting new admissions to any nursing facility;
  2. Petitioning the court to impose a civil penalty or to appoint a receiver, or both; or
  3. Revoking or suspending the license of a nursing facility.

The results of a FOIA request inform me that not one of them has ever used that authority.

Not once in 34 years. 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

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

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

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