The Canterbury Tragedy and the Failed Virginia Department of Health

Key metrics for Canterbury Rehabilitation (also known as Lexington Court). Source: Virginia Health Information

by James C. Sherlock

One of the issues we are facing with the decline of regional newspapers is the decline of investigative reporting. The few reporters left in Virginia covering the Northam administration are printing press releases as stories and reporting press conferences for what is said, not what is unsaid or wrong. The national newspapers focus on President Trump. An article in the New York Times on the Canterbury disaster failed to mention the Northam administration at all, even though that facility is Medicaid funded and the state has a responsibility to oversee (Department of Medical Assistance Services (DMAS)), inspect and license (Virginia Department of Health (VDH)) it.

States have a contract with the Centers for Medicare/Medicaid Services (CMS) to monitor those nursing homes that want to be eligible for Medicare and Medicaid.  Canterbury Rehabilitation and Health Care Center is one of those.  Nursing facilities are inspected by VDH Division of Long Term Care:

  • every 2 years for Virginia state licensure; and
  • an average of every 12 months for Medicare/Medicaid certification.

Out of a potential five stars in the rating of nursing homes by Medicare based on VDH inspections, 59 of 286 Virginia nursing homes have been rated one star, a Much Below Average rating. Nine of those have been cited for abuse.

Canterbury Rehabilitation and Health Care Center in Richmond is the location of the largest number of nursing home deaths from COVID-19 in the country.  At the onset of the COVID-19 scourge, it was rated two stars overall (Below Average) and one star (Much Below Average) in health inspections and staffing.  The Canterbury facility is about a 20 minute drive from VDH headquarters.

I had an extensive email exchange last year with VDH about one-star rated hospitals — specifically asking what the Commonwealth was doing to improve them. I recommended the state ask for letters of correction from one-star hospitals. The answer was no. They would not require letters of correction with specific actions and milestones. By VDH policy they do nothing, just inspect and report.

I reported here[1] on February 22 that the nursing home representative on the State Board of Health[2] is the CEO of Heritage Hall, a chain of nursing homes. See this for the Medicare ratings of those nursing homes. Of the 17 Heritage Hall facilities in Virginia, one is graded as having average staffing, the rest below average or much below average. In overall ratings, nine of the 17 are rated below average or much below average. Heritage Hall has contributed more than $100,000[3] to political campaigns over the years, mostly through the Virginia Hospital and Healthcare Association (VHHA).

So, no, the federal government does not ensure that Virginia’s nursing homes treat their patients well and protect them from harm. CMS levies fines for the worst offenses, but they are generally not large enough to change facility behavior. State regulators still need to take action if behavior is to be changed, such as mandating specific changes to the way the home operates by requiring a letter of correction from the operator and ensuring it is executed. It is hard to square properly corrected actions, especially staffing shortfalls, with the year-after-year one-star nursing home ratings in Virginia.

The Northam administration is directly responsible for inspection and licensing of Canterbury Rehabilitation and Health Care Center in Richmond. The facts that signaled the vulnerability of the institution to pandemic virus were gathered and reported by the Commonwealth itself. From news reports, staffing shortfalls at Canterbury were still a problem with the onset of the pandemic.

The Virginia Department of Health is a failed institution with a failed leader, Dr. Oliver.  No amount of hand waving and misdirection will change that fact.  We need a new Health Commissioner.  Too late for a new Governor.




Note: Part of this column has been re-written since its original publication. — JAB