Category Archives: Long Term Care and Nursing Homes

Predatory Virginia Nursing Home Owners

Posted on June 22, 2023 by | 22 comments

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 →

22 Comments

Posted in Consumer Protection, Corruption and Scandals, Crime, Corrections and Law Enforcement, Ethics, Federal issues, Health Care, Insurance, Long Term Care and Nursing Homes, Medicaid, Regulations and Government Oversight

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

Posted on June 19, 2023 by | 11 comments

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 →

11 Comments

Posted in Consumer Protection, Corruption and Scandals, Crime, Corrections and Law Enforcement, Health Care, Leadership, Long Term Care and Nursing Homes, Public safety & health, Regulations and Government Oversight, Social Services and Entitlements

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Virginia Nursing Home Regulations and Inspections – A Strategic Improvement Recommendation

Posted on June 13, 2023 by | 2 comments

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 →

2 Comments

Posted in Federal issues, Health Care, Long Term Care and Nursing Homes, Public safety & health, Regulations and Government Oversight

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

Posted on June 12, 2023 by | 6 comments

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 →

6 Comments

Posted in Consumer Protection, Ethics, General Assembly, Health Care, Long Term Care and Nursing Homes

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

Posted on June 10, 2023 by | 28 comments

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 →

28 Comments

Posted in Consumer Protection, Courts and law, Crime, Corrections and Law Enforcement, Efficiency in Government, General Assembly, Governance, Government Transparency, Health Care, Long Term Care and Nursing Homes, Medicaid, Money in politics, Regulations and Government Oversight

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The Registered Nurse Shortage

Posted on March 20, 2023 by | 72 comments

by James C. Sherlock

I have reported often about the severe and increasing shortages of nurses both in Virginia and nationally.

At some point in nearly everyone’s life, we literally will not be able to live without the help of a nurse, whether for injury or illness or just declining overall health.

We need both the nurses and ourselves to be safe when that happens. We will have to fill the shortages, first by recruitment and retention. Perhaps simultaneously by increased legal immigration of qualified nurses from other countries.

This article will focus first on what RNs were paid in 2021, both in Virginia and nationwide. We will examine it in absolute and in relative terms. Virginia in 2021 was competitive on pay in relative terms. But wages may be insufficient in absolute terms to address the shortages.

Then we will discuss what else needs to be done to recruit, train and retain more nurses. I mentioned in an earlier article that RN instructors in training programs are one of the biggest needs.

The Census Bureau and Bureau of Labor Statistics have captured the large increases in registered nurse (RN) pay across the board and the doubling of the pay of travel nurses in 2021. Those pay surges were driven by COVID supply and demand and funded partially by federal emergency money.

You will see that, by what I consider a useful calculation, Virginia RN’s median wage compensation is 18th among the states when adjusted for each state’s cost of living index. Virginia is the top-paying state among adjacent states and the District of Columbia.

Regardless of the reason, it was past time that we paid them more. We need the pay raises to stick. It is the only way over the long run to begin increasing the supply.

I say begin because there are other factors driving nurses away. Safety is a huge factor. Continue reading →

72 Comments

Posted in Ethics, Health Care, Immigration, Labor and Workforce, Long Term Care and Nursing Homes, Regulations and Government Oversight

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New Fed Policy Would Hide CMS Data on Patient Safety Records of Hospitals

Posted on July 7, 2022 by | 13 comments

by James C. Sherlock

One of the most disturbing commentaries I have read in a long time relating to federal efforts to improve hospital patient safety reports a major step backwards in that program.

I have written here many times of the power of the hospitals over Virginia’s politics. A proposed new federal rule shows that power at the federal level. It would negatively affect your ability to understand and compare the patient safety records of hospitals.

The Biden administration Centers for Medicare/Medicaid Services (CMS) proposes to hide from the public a CMS rating that helps consumers view relative patient safety grades of hospitals. As important to the hospitals, perhaps, no one would be able to report on that information.

It also proposes to waive $350 million in fines for hospitals that violated existing regulations.

CMS for the Secretary of Health and Human Services is, with this rule, exercising the extraordinary powers the Secretary gives himself by constantly extending the Declaration of Public Emergency for COVID.  And yes, that is legal.

Virginia Hospital and Healthcare Association (VHHA) submitted a 17-page letter of comment. It of course supported the waiver of fines.  On the issue of suppressing patient safety data, the VHHA wrote, unsurprisingly:

“VHHA and its members are supportive of the proposed suppression (of data) in the HVBP program.”

The letter also encouraged CMS to also suppress pneumonia mortality measure because of the potential overlap with COVID- related pneumonia.

The only way that could happen since CMS is already suppressing data with a primary or secondary COVID diagnosis is if there was no reported COVID indication in pneumonia cases.

The proposal itself represents a major scandal.  A total of 1,533 comments, now closed, were submitted on the proposed rule.

They comments from doctors and patient safety groups were unsupportive.  Hospitals were very supportive.  The Virginia Department of Health sent a short letter on the larger rule, but did not comment on data suppression.

The result: political healthcare rules courtesy of the Biden administration and the hospital lobby.

The following article is reprinted by permission of Kaiser Health News. Continue reading →

13 Comments

Posted in Consumer Protection, Federal issues, Government Transparency, Health Care, Long Term Care and Nursing Homes, Money in politics, Political Influence, Public safety & health, Regulations and Government Oversight

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Medicaid, Public Health and Chronic Disease Management

Posted on May 29, 2022 by | 6 comments

UVa Hospital

by James C. Sherlock

From the CDC:

Chronic diseases have significant health and economic costs in the United States. Preventing chronic diseases, or managing symptoms when prevention is not possible, can reduce these costs.

Virginia pays a great deal of money every year to contractors who manage the care of its Medicaid population.

It is a hard job, but even though the challenges are tough, it has appeared to me for a long time that we are not getting our money’s worth from $18 billion annually in Medicaid payments for the populations managed by these contractors.

A white paper, “Prevent Costly Chronic Disease Through Member Engagement” caught my eye as the basis for a follow up to my earlier report on public health and Medicaid managed care in Petersburg.

This is that update. Continue reading →

6 Comments

Posted in General Assembly, Government Finance, Health Care, Insurance, Long Term Care and Nursing Homes, Mental illness and substance abuse, Public safety & health, Regulations and Government Oversight

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Unionize Virginia’s Worst Nursing Home Chains

Posted on April 25, 2022 by | 8 comments

by James C. Sherlock

If you go back to the series of articles I published here in October of 2021, you can refresh your memory on the dangers represented by Virginia’s worst nursing home chains.

If you look at the complete spreadsheet of every Virginia nursing home from that data sorted by ownership, the bad actors jump off the page. Their business models treat understaffing as a feature, not a problem. The fact that it endangers their employees and kills their patients seems not to matter.

The Commonwealth’s executive and legislative branches have for a very long time absolutely ignored their responsibilities as the state legislature and as the state executive regulator, federal and state inspector and state licensor of nursing homes, respectively. There is as yet no sign that will improve. I have hopes the new administration will step up to those responsibilities, but we’ll have to wait and see.

For now, the only fix that appears viable is unionization of the work forces of the bad actors. I encourage their employees to do it for themselves and their patients. Continue reading →

8 Comments

Posted in General Assembly, Governance, Health Care, Labor and Workforce, Long Term Care and Nursing Homes, Political Influence, Regulations and Government Oversight, Unions

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A Narrative About Virginia’s Rural Hospitals that Obscures the Facts

Posted on March 8, 2022 by | 12 comments

by James C. Sherlock

Becker’s Healthcare, a widely read medical news organization, published a story on Friday, “892 hospitals at risk of closure, state by state.” Rural hospitals were the topic.

It cited as its source a report from a non-profit named The Center for Healthcare Quality and Payment Reform (CHQPR), which presents itself as “a national policy center that facilitates improvements in healthcare payment and delivery systems.”

The CHQPR report Rural Hospitals at Risk of Closing claims that twelve of Virginia’s “27″ rural hospitals are at immediate risk of closing. It certainly engaged my interest.

Another CHQPR report, The Crisis in Rural Health Care, has an interactive map where the twelve perhaps can be found.

But the sources of both reports are a mystery, at least to me.

  • First it must be noted that the Virginia Department of Health lists only 20 rural hospitals in the state.
  • Only five of them lost money in 2020 (see the column “Revenue and Gains in Excess of Expenses and Losses”).
  • Four of those are owned by large and profitable health systems that use them to feed more profitable cases to other system hospitals.

It is dangerous to the cause of improving rural healthcare to create “reports” like this. Continue reading →

12 Comments

Posted in General Assembly, Government Finance, Health Care, Long Term Care and Nursing Homes

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Big Lessons from Government Data on Virginia’s 286 Nursing Facilities

Posted on October 13, 2021 by | 8 comments

by James C. Sherlock

Nursing facilities in Virginia offer an incredible mixed bag. There are heroes and villains. Much to see here.

This column will offer expansive  views of government data on each of the 286 nursing facilities in this state.  

I found out a lot things that really matter to the quality of a nursing facility in Virginia. And a lot of things about government oversight.  nd government insurance payments.

From the visualization aids I provide, so will you.

  • You will find absolutely outstanding facilities.  
  • You will find others that have fallen so short of government standards for so long that you will wonder why Virginia does not revoke their licenses.  
  • You will see the nursing homes in your region.  
  • You will see which chains deliver excellent facilities and which do not, apparently as business models in both cases. Many chains tend to be consistently good or consistently bad. They are color coded in the “Group Ownership” column based upon the overall performance of the chain.  
  • Take a look at the staffing star ratings. Those are based on quarterly filings of data that is linked to payrolls, so it is relatively up to date and relatively accurate. One- or two-star staffing is a very bad sign.
  • You will see the stunning outperformance of nursing facilities in continuing care facilities in Virginia, also as a function of business models.
  • Nursing home inputs — people — enter nursing homes in much different physical conditions and ages. You will see that where you live is a statistical predictor of health. And therefore of the nursing home challenges in areas of poor health. Which tracks with areas of poverty. And low government insurance payments.

Finally, take a look at the Inspection activity.  

It reflects the massive understaffing of the VDH inspectors. Look at the “Last standard (full) health inspection” column. You will see coded in red that 42 (15%) of Virginia’s nursing facilities have not been fully inspected since 2018.  The federal requirement is once a year.  

You will be convinced by the data that strict and timely government oversight is required to ensure, and ensure Virginians of, of nursing facility quality.  

The state must fix the statutory and budget issues that have resulted, purposely, in Office of Licensure and Inspection staffing shortfalls. Continue reading →

8 Comments

Posted in Demographics, Health Care, Long Term Care and Nursing Homes, Regulations and Government Oversight

Nursing Home Ads Pose As Official State Advice

Posted on October 12, 2021 by | 9 comments

by James C. Sherlock

The Virginia state government has a Department for Aging and Rehabilitative Services. 

Who wouldn’t want one of those?  

But in the case of recommending nursing homes, it would be better if it would either stop or fix its broken system. Which it pays a nonprofit, VirginiaNavigator, to run.

It is offering nothing more than free, self-written advertisements for good and bad nursing homes alike under the guise of a state recommendation to seniors. Continue reading →

9 Comments

Posted in Efficiency in Government, Governance, Health Care, Long Term Care and Nursing Homes, Regulations and Government Oversight

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Virginia’s Self-Inflicted Nursing Home Crisis – Part 5 – The Best facilities in Virginia

Posted on October 4, 2021 by | 1 comment

by James C. Sherlock

To show you the list of nursing facilities that I would use to begin a search for one for me and my family, I have built a spreadsheet of the very best facilities in Virginia.

Because they are available, I made it a true list of all stars. Five stars composite rating and not a single individual rating below four stars.

There are 40 of them, surprisingly and welcomingly spread around the state. If you read my previous posts, or read the notes on the spreadsheet, I don’t have to comment extensively.

Eight of them are for-profits.  So it can be done. Continue reading →

1 Comment

Posted in Health Care, Long Term Care and Nursing Homes

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Virginia’s Self-Inflicted Nursing Home Crisis – Part 4 – the Worst Facilities in Virginia

Posted on October 4, 2021 by | 7 comments

by James C. Sherlock

Today we are going to take a look today at a snapshot of Virginia’s worst nursing homes as rated by the Centers for Medicare/Medicaid services.

Medicare rates 54 of the total of 288 nursing facilities in Virginia as overall one star out of five.  By definition of the way that Medicare compiles records and assigns scores, they have been bad for a long time.

Don’t use them. If you have any friend or loved one in one of these places encourage them to re-locate if they can. Either way, visit them often. It helps.

The ratings are established in considerable part by the inspections conducted by the Virginia Department of Health Office of Licensure and Inspection.

Continue reading →

7 Comments

Posted in Health Care, Long Term Care and Nursing Homes, Regulations and Government Oversight

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Virginia’s Self-Inflicted Nursing Home Crisis – Part 3 – McAuliffe & Herring

Posted on October 2, 2021 by | 4 comments

by James C. Sherlock

In the first two parts of this series, I wrote about the shortage of state inspectors for nursing homes in the Virginia Department of Health Office of Licensure and Certification (OLC)  and the continuing danger it poses to Virginia patients.

The problem, unfortunately, is much wider than just nursing homes.  So is the scandal.

That same office inspects every type of medical facility including home care agencies as well as managed care plans. Except it cannot meet the statutory requirements because it does not have sufficient personnel or money. And it have been telling the world about it for years.

Terence Richard McAuliffe was the 72nd governor of Virginia from 2014 to 2018. Mark Herring has been Attorney General since 2014.

We will trace below that they can reasonably be called the founding fathers of overdue inspections of medical facilities in Virginia.

VDH has been short of health inspectors since McAuliffe and Herring took office and still is .

Both of them know it. And they know that lack of inspections demonstrably causes unnecessary suffering and death.

Continue reading →

4 Comments

Posted in Consumer Protection, Corruption and Scandals, Ethics, General Assembly, Governance, Health Care, Long Term Care and Nursing Homes, Money in politics, Political Influence, Regulations and Government Oversight

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