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.
I am not going to reiterate here my series on the ills of Virginia’s nursing homes except that they house the most vulnerable citizens in our society and, on balance, while there are many honorable exceptions, Virginia’s system of 287 nursing facilities is among the worst in the nation.
Lots of reasons for that, but you may find as I have that the NAS teased out the most critical shortfalls addressable at the state and facility level and offers remedies for them.
And yes, they most certainly mean Virginia. And, no, JLARC does not need to study it further.
Here they are – quoted. The Rec. references are to exhaustive source discussions in the text of the report.
Combination of federal agencies, state governments, and nursing homes
Emergency Preparedness.
Rec. 1.D. To ensure the safety of nursing home residents, enforce existing regulations, including
- Every nursing home has a written emergency plan (including evacuation plans) for common public health emergencies and natural disasters in the facility’s location, created in partnership with local emergency management and resident and family councils; plan reviewed and updated at least once every year.
- Nursing home staff are to be routinely trained in emergency response procedures as well as in the appropriate use of PPE and infection control practices.
- Every nursing home has an emergency preparedness communication plan that includes formal procedures for contacting residents’ families and staff to provide information about the general condition and location of residents in the case of an emergency/disaster.
Documentation of emergency plans as well as the conduct of emergency drills and staff awareness of emergency management plans to be added to Care Compare. (CMS, through state regulatory agencies)
Wages and Benefits
Rec. 2.A. Ensure competitive wages and benefits (including health insurance, child care, 2A and sick pay) to recruit and retain all types of full- and part-time nursing home staff. Consider the following mechanisms: wage floors, requirements for minimum percentage of service rates directed to labor costs for the provision of clinical care, wage pass-through requirements, and student loan forgiveness. (Federal and state governments, together with nursing homes)
Rec. 2.E. Make available free entry-level training and continuing education for CNAs. (Federal, state governments, nursing homes)
Rec. 2.F. Provide flexible, low-cost, and high-quality pathways for nursing home staff to achieve baseline education and competency levels. (CMS and nursing homes)
Staffing
Rec. 2.C. Update the regulatory requirements for staffing standards in nursing homes to reflect new minimum requirements and account for case mix based on research on minimum and optimum staffing standards for direct care staff. (CMS and state governments)
Oversight and Enforcement
Rec. 5.D. Impose oversight and enforcement actions on the owner when data on the finances and ownership of nursing homes reveal a pattern of poor-quality care across facilities with a common owner (including across states). Actions may include: denial of new or renewed licensure, imposition of sanctions, and implementation of strengthened oversight (e.g., through a broadened special focus facilities program). (Federal and state oversight agencies [e.g., CMS, state licensure and survey agencies, DOJ]). (Author would add the Virginia Attorney General who has the state Medicaid Fraud unit.)
States
Management and Coordination
Rec. 1.D. Ensure the development and ongoing maintenance of formal relationships, including strong interface, coordination, and reliable lines of communication, among nursing homes and local, county, and state-level public health and emergency management departments. (State regulatory agencies with federal oversight from FEMA and CMS)
Emergency Preparedness.
Rec. 1.D. Ensure that nursing homes are represented in
- State, county, and local emergency planning sessions and drills
- Local government community disaster-response plans
- Every phase of local emergency management planning, including mitigation, preparedness, response and recovery
- Every nursing home has ready access to personal protective equipment (State emergency management agencies)
Construction and Renovation.
Rec. 1.E. Ensure that all new nursing homes are constructed with single-occupancy bedrooms and private bathrooms for most or all residents. (State licensure agencies)
Ombudsman
Rec. 5.C. Advocate for funds to LTC ombudsman programs to address cross-state variations in advocacy capability.
Develop plans for LTC ombudsman programs to interface effectively with collaborating entities such as adult protective services, state survey agencies, and state and local law enforcement agencies. (State units on aging)
Competition
Rec. 5.E. Eliminate certificate-of-need requirements and construction moratoria for nursing homes to encourage the entry of innovative care models and foster robust competition in order to expand consumer choice and improve quality.
Nursing Home Owners/Administrators
Care Planning
Rec. 1.A. Ensure that each element of the resident care planning process is conducted in an accurate, comprehensive, and appropriate manner for each resident to promote person-centered high-quality care that reflects resident and family preferences. Interdisciplinary care team members make certain that every resident’s care plan addresses psychosocial and behavioral health as well as nursing and medical needs. Care plan to be reviewed and evaluated on a regular basis. (Nursing homes, with oversight by CMS)
Construction and Renovation
Rec. 1.E. Construct and reconfigure (renovate) nursing homes to provide smaller, more home-like environments or smaller units within larger nursing homes with single-occupancy bedrooms and private bathrooms. This shift to more home-like settings should be implemented as part of a broader effort to integrate the principles of culture change, such as staff empowerment, consistent staff assignment, and person-centered care practices, into the management and care provided within these settings. (Nursing home owners with the support of federal and state governmental agencies)
Specialist Professionals
Rec. 2.D. Establish consulting or employment relationships with qualified licensed clinical social workers at the M.S.W. or Ph.D. level, APRNs, clinical psychologists, psychiatrists, pharmacists, and others for clinical consultation, staff training, and improvement of care systems as needed to enhance available expertise.
Mentoring
Rec. 2.E. Provide career advancement opportunities and peer mentors for CNAs; cover CNAs’ time for completing education and training programs.
Diversity and Inclusion Training
Rec. 2.G. Provide ongoing diversity and inclusion training (e.g., self-awareness of and approaches to addressing racism) for all workers and leadership, and ensure training is designed to meet the unique demographic, cultural, linguistic, and transportation needs of the community in which the nursing home is situated and the community of workers within the nursing home.
Family Involvement
Rec. 2.G. Provide family caregivers with resources, training, and opportunities to participate as part of the caregiving team in the manner and to the extent that residents desire their chosen family members to be involved.
Bottom line. Sometimes we have to defer to those who have studied the problems and assessed the viability of solutions more thoroughly and with more rigor than we ever could.
I personally defer in this case.
While some may find nits, critiquing that work as a whole is, in my view, a fool’s errand.
I finished the whole thing, and found no evidence of any philosophical/political bias. Even the diversity and inclusion training makes perfect sense in the context in which it is recommended.
I recommend that the Youngkin administration and the General Assembly work to get these recommendations as a package in the law in a jointly sponsored bill stating intentions.
I recommend they try not to have a fight over every specific in order to put a stake in the ground for the future of Virginia law and regulation.
Individual bills for parts of the package are appropriate for the regular 2024 session, as are budget elements to support them. Some are straightforward, such as the recommendations for emergency preparedness and enforcement.
Virginia law must also clearly recognize the primacy of the Social Security Act and federal regulations for nearly all Virginia nursing homes. Put simply, Virginia can have higher standards than those of the federal government, but not lower.
The costs to the state for those provisions will be relatively small. The costs for some of the others will have to be reimbursed by Medicaid.
I recommend the Governor and GA concentrate on immediately improving the staffing and staff funding for the Office of Licensure and Certification (OLC), which enforces both federal and state nursing facility laws and regulations. And while they are at it make sure that OLC staff nurses are paid enough to attract the best candidates.
OLC, in combination with the Centers for Medicare/Medicaid Services, enforces federal laws and regulations in Medicare/Medicaid surveys and the levying of sanctions under federal guidelines. They also conduct state licensing inspections and levy sanctions under state guidelines.
For the same nursing homes.
There is no reason that the rules should be different unless the state means to be stricter.
As an administrative procedure, federal nursing home laws and regulations can be adopted by reference in their Virginia counterparts, so that when they change, as the regulations are about to do, Virginia is in compliance automatically.
Give the emergency preparedness programs any money they may need to include nursing home preparedness.
Other recommendations in the package should be brought forward when ready, and may take a special session, but so be it.
The current situation is demonstrably inhumane.
