Virginia Department of Health and the Staffing of Nursing Homes

by James C. Sherlock

Virginia announced on Friday that the state’s tally of COVID-19 deaths in long- term care facilities had reached 311. That can be traced at least in part to understaffing of nurses in nursing homes such as Canterbury (49 deaths) in Richmond in which Virginia’s sickest un-hospitalized patients reside.

Under Dr. Oliver’s leadership, the Virginia Department of Health has failed in its job to ensure its nursing homes are properly staffed. The Centers for Medicare/Medicaid Services 5-Star Nursing Home Compare system rates more than half of Virginia nursing homes as below (2 stars) or much below (1 star) national averages in the metric of registered nurse staffing that is critical to the care of patients. Virginia finds itself among the bottom 10 states in those staffing rankings.

This essay will provide evidence that nurse staffing deficiencies appear not to be consistently and properly reported in inspections, leaving operators unthreatened by corrective actions that require major expenditures in hiring additional nurses.

Nursing homes offer the most extensive care one can get outside a hospital. Nursing homes offer help with custodial care — activities of daily living — as well as skilled nursing care.

Skilled nursing care is given by a registered nurse and includes medical monitoring and treatments. Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.

Americans have three public obligations to persons in nursing homes:

  1. We must make sure that the two primary public programs that pay for nursing home care, Medicaid and Medicare, provide sufficient funding and other resources to enable operators of those nursing homes to provide excellent care and make a enough profit to protect and increase the supply as the population ages. Medicare supports its beneficiaries in short-term recovery in skilled nursing facilities. Medicare payments are set for the federal government by the Centers for Medicare/Medicaid Services (CMS). Medicaid supports the poor in both nursing facilities (NFs) and skilled nursing facilities (SNFs). Medicaid payments are set by each state.
  2. We must set standards of care at every level of patient disabilities. In support of Social Security Act provisions, CMS sets those standards of care for the Medicare and Medicaid programs. Nearly every nursing home seeks certification for participation in those programs, so the CMS standards are effectively national standards.
  3. We must inspect to ensure standards are met. CMS and the state survey agencies (SSAs) that conduct Medicare and Medicaid nursing home inspections for CMS certification must enforce those standards with inspections and penalties sufficient to protect both workers and patients. I have seen estimates that 50% – 70% of nursing home patients are affected to different degrees by dementia. They often cannot speak effectively for themselves.

Even if this was not the moral obligation that it most certainly is, it is also a financial necessity. Older persons with chronic illnesses and geriatric conditions frequently do not receive optimal care and account for a disproportionate share of healthcare expenditures. Improved care for patients with multiple chronic conditions has high potential for reducing preventable hospitalizations as well as helping older adults with multiple chronic conditions have a higher quality of life and stable environments as they age.

Each state has the responsibility to inspect and certify nursing home compliance or noncompliance with federal inspection criteria, except in the case of state-operated facilities that CMS inspects. In addition to certifying a facility’s compliance or noncompliance, the state survey agency (SSA) for nursing homes, in Virginia’s case the Virginia Department of Health (VDH), recommends appropriate enforcement actions to the State Medicaid agency for Medicaid and to CMS for Medicare and Medicaid.

The performances of SSAs have been wildly inconsistent. This resulted in an October, 2019, CMS memo to the SSA directors that announced strengthened oversight of state agencies’ performance in nursing home inspections relative to measures included in the State Performance Standards System (SPSS). Virginia may prove to be a target of that oversight.

Skilled nursing facility and nursing facility standard surveys are conducted by a multidisciplinary team of professionals, at least one of whommust be a registered nurse.

One key standard is staffing. Work in nursing homes is very demanding.

Staffing is so important and nurse staffing so specific to the patient populations of individual nursing homes that CMS has established two systems to measure it:

  1. a CMS system that calculates a staffing ranking based on auditable payroll-based data and adjusted for patient population and individual care needs. It ranks staffing on a 5-star scale comparing the staffing in general and registered nurse staffing in particular of each facility to national averages; and
  2. an inspection system with protocols to measure staffing against specific patient outcomes. CMS directives require the teams to prepare for each inspection with an extensive records search including both recent inspection results and data in the CMS databases including the 5-star ratings data. Part of those data are the results of the payroll-based journal (PBJ) system. Sufficient and Competent Nurse Staffing assessment is a key task assignment for the team. All surveyors are charged with assessing this task while one surveyor has primary responsibility.

I conducted a project to assess staffing in Virginia nursing homes with analysis of both payroll-based results and inspection results for Canterbury Rehabilitation & Health Care Center (ex Lexington Court) in Richmond, Virginia, the site of the highest COVID-19 death toll in America. It had been reported as understaffed in its most recent inspection and was rated one-star in its Oct-Dec 2019 payroll-based data submitted to CMS.

Staffing hours per resident per day is the total number of hours worked by the staff member(s) divided by the total number of residents. The one-star rating for RN staffing indicates around 1/3 of registered nurse (RN) staffing hours available compared to the average nursing home in the United States. Because of understaffing Canterbury staff and patients  were more vulnerable to COVID-19 than those of the majority of nursing homes.

Canterbury was not an isolated situation, but rather a more pervasive one in here. Forty seven of Virginia’s 268 Medicare and Medicaid nursing homes in Virginia are currently rated as one star (much below average) in staffing.

Sufficient staffing is achievable. Nine states and the District of Columbia each have fewer that 10% of their nursing homes with below average staffing. Florida with its massive population of older people has only 11% of it nursing homes with identified below or much below average staffing.

The nursing work in nursing homes is so difficult and time consuming and the standards of care high enough that as a practical matter nursing homes so thinly staffed as those with one star staffing grades cannot be expected to meet standards of care. That abuses both patients and staff. The only solution to nursing shortages in to hire more nurses.

I then spent a great deal of time assessing inspection results at four large NF/SNF chains in Virginia with CMS-documented staffing issues similar to those at Canterbury.

The federal Sufficient Staff regulations for long term care facilities include:

(1) The facility must provide services by sufficient numbers and types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans
(2) The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments and described in the plans of care.
(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs.

Federal requirements for registered nurse staffing are also specified. Except when waived under special circumstances,
(1) The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.
(2) The facility must designate a registered nurse to serve as the director of nursing on a full time basis.
(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Nursing home inspections in Virginia appear to fail to report significant staffing deficiencies seen in CMS PBJ staffing data. A disproportionate share of that underreporting is seen in inspection results from Virginia’s largest nursing home chain, Heritage Hall Healthcare and Rehabilitation Centers.

I constructed a detailed spreadsheet with the data from this assessment. The inspection results do not match Heritage Hall’s current payroll-based staffing ranking. They are also inconsistent with the fact that multiple staffing deficiencies were recorded for three other comparable Virginia nursing home chains with as good or better current CMS staffing ratings as Heritage Hall.

Findings of my assessment included:

  1. Documented inspection deficiencies in nurse staffing are the only government oversight function that forces nursing homes to hire additional nurses. One additional RN can cost the business in excess of $100,000 annually.
  2. Current CMS PBJ-based staffing data shows below average or much below average staffing in 15 of 16 of Heritage Hall facilities and indeed most of the facilities in the state.
  3. I saw no evidence in the inspection deficiencies reported that inspection teams adequately considered CMS staffing data in their preparations for the inspections. They may have done it, but it simply does not show up in the deficiency reports at the rate that would be expected. Someone with access to the CMS staffing data for the quarter during which each inspection was conducted will need to verify that disconnect.
  4. A complete review of 51 VDH inspection reports for Heritage Hall facilities over the past three years revealed  217 deficiencies in categories such as Quality of Life and Care and Resident Assessment and Planning that can indicate that the Heritage Hall nursing staffs were not keeping up in their work.
  5. In that same three year cycle, there was not a single inspection-related nursing services deficiency recorded for Heritage Hall that reflected nursing shortages. Indeed one Heritage Hall facility holds a one-star registered nurse staffing rating from Medicare for the Oct-Dec 2019 quarter. It was last inspected by VDH on 12 September 2019 and holds a 5-star inspection ranking.
  6. Heritage Hall’s competitors with similar staffing rankings were cited in some inspections over those three years with nursing services deficiencies indicating shortages.

The assessment sample size is so large that the differences between the inspection results for Heritage Hall facilities and those for other Virginia nursing homes display strong statistical significance, as do the differences between CMS staffing rankings and nurse staffing deficiencies noted in VDH inspections.

So not only have VDH inspections demonstrably been lax in reporting nurse staffing deficiencies in nursing homes compared to most states resulting in state’s the bottom 10 ranking in staffing, they seem to have a particular blind spot for the nursing homes of Heritage Hall. This is wrong, dangerously so, at many levels.

An investigation is appropriate. I hope CMS will conduct one.

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29 responses to “Virginia Department of Health and the Staffing of Nursing Homes

  1. Jim – I have to say your posts are very thorough and obviously the result of a LOT of work – you cannot possibly have all this stuff in your head!

    My impression of how political thinking/philosophy “works” for issues like nursing homes generally is along the lines of Dems wanting proscriptive regulations that can directly drive costs up to more Conservative folks thinking regulation is not such a good thing but outcome-based metrics being better because it allows those responsible to find the most cost-effective ways to achieve desired outcomes.

    Somewhere in the middle of this there must be a secret sauce – and certainly one of them is the management of the facility itself. Good management will achieve both cost-effectiveness as well as the desired outcomes whereas poor management will waste resources and have bad outcomes also.

    So on the staffing issue – that’s been a disputed area between Dems and GOP for some time where Obama tried to put a regulation that there actually had to be a staff person whose sole job was monitoring infectious-disease efforts and Trump has sought to roll that back.

    So I’m not characterizing this as a partisan issue – I’m just illustrating the two divergent approaches that seem to be in play – at least sometimes on some issues.

    So the staffing is the thing… and that begets the regulation and enforcement as well as sanctions…

    And I do not disagree with your analysis that there are some nursing homes – that just do not do well when it comes to staffing – while others apparently do.

    But I wonder when push comes to shove – what the State could actually accomplish if they essentially put some nursing homes out of business for bad performance; in terms of costs – the state would incur huge costs in trying to find new homes for displaced residents… because nursing homes being private businesses do not have to take anyone and especially if they think taking on more would cause cost and staff issues.

    It seems like there has to be more than just enforcement and sanctions if we need to retain nursing home capacity and not cause shortages.

    I actually have one idea. VDOT will offer incentives for work performed as stipulated and ahead of schedule.

    Why not offer nursing homes incentives for better outcome metrics?

    Another idea: The state stands up regional nursing homes that are designed to receive patients that are moved from underperforming nursing homes?

    Again – thank for your work.

  2. Jim, your narrative suggests that VDH chieftain Norman Oliver is to some degree responsible for the negligent inspections of Heritage Hall nursing homes — the failure occurred “under his leadership.” Do you have any indication that he stands out in some way among VDH chiefs? Have you gone back to see the pattern before COVID-19? I’m sure that would be a tremendous amount of work. But it’s a fair question to ask if this is an institutional failure or a personal/political failure that transcends one individual’s tenure.

    • Yes I have gone back before COVID-19. In fact, as I reported in my essay, the current payroll data from CMS on staffing was from the fourth quarter of 2019.
      Dr. Oliver has been in charge at VDH for more than two years. The inspection data available to me don’t go back but three years, and the CMS staffing data that I can access are only from October to December 2019. I did a lot of work with that data, but as I said in the essay, someone with access to more data than I will have to investigate.
      However, there is no excusing the underlying fact that Dr. Oliver could have accessed the same data I did and figured out that something was amiss. If more than half of the nursing homes that you inspect in your state are rated by Medicare as understaffed, it has to raise questions. That information doesn’t take a deep dive, just a passing interest. He wasn’t interested.
      It clearly is up to CMS investigators to determine the source of the problem, but two years in charge is enough time to have fixed it.
      We simply cannot give him a pass, or who ever will feel accountable?

  3. The “hold them accountable” mentality is tenuous at best in my view.

    Let’s take something like the prisons – Are we going to hold the top guy
    of the prison system “accountable” because a lot of prisoners got infected?

    Or we’re going to hold the head of VDOT “accountable” because a bridge fails… or a traffic signal malfunctions and someone died? Or the Superintendent of Public Education “accountable” because not all kids graduate.

    I’m not saying there can never be a situation where there is malfeasance… but you really have to have compelling evidence that shows a pattern or a policy failure that goes directly to something the leadership actually did to cause that failure.

    Just being the head of an agency does not make you “accountable” for every bad thing that happens.

    it’s really a bridge to far to take something like nursing homes having problems during a pandemic as an example of bad leadership especially when it’s going on in other states also.

    Finally, if there is going to be a legitimate action – it cannot be just from the strident critics or partisans. There has to be some level of general agreement with non-critics and non-partisans.

    That dog just don’t hunt.

    • Read my reply to Jim Bacon above. We are Virginians. Your answer seems to suggest that there can never be personal accountability for government failures in Virginia. The data that are available suggest the failures are ongoing. Tell me how you would assess accountability other than the person in charge for more than two years. If there is to be no accountability, then nothing will change.
      Remember that at election time when you allocate all accountability for federal missteps to President Trump.

      • Jim – Does CMS see these as “failures” and if they do then what is their action? I KNOW they DO take action and withhold Medicare/Medicaid so why not in this case if it is that bad?

        Once again – it’s not either/or – i.e. Failure and accountability or failure and no accountability.

        And how in the world do you bring Trump into this?

        We’re talking about career bureaucrats here not politicians.

        Just to be clear – I do NOT hold Trump “accountable” for things like the Roosevelt debacle or any other “failure” down the food chain that he had nothing to do with. I judge him on the things he DOES have something to do with – top level policies… not if some Border patrol guy went off the ranch and did bad stuff.

        If the head of VDH actually took some action to stop or change long-standing enforcement that had been the standard or the norm – and the result was a failure – YES – but if he was following standard practice and policy – and there were already problem nursing homes that CMS was also not taking action against – then why is he singled out?

        This “hold them accountable” mentality that is popular with Conservatives when the opposite party is in control but it subsides when their guy is in control is just partisan stuff.

        If Oliver is truly bad – I want to hear it from those who are not standard political critics of the opposite stripe.

        Coming from partisans – it just lacks credibility…

        • The controlling facts are these:
          – The leader of the state agency responsible for the health and safety of Virginians in nursing homes took no action for more than two years to correct the very visible fact that they are endangered by widespread understaffing.
          – His agency is responsible by law to act for the federal government in annual Medicaid/Medicare certification inspections.
          – Federal penalties are levied only based on those inspections.
          – His inspection division quite traceably failed to report staffing deficiencies that those nursing homes had self-reported quarterly to CMS based on daily payroll data. One nursing home chain in particular was notably fortunate in those inspection results.
          – Virginia nursing homes saved millions of dollars in staffing costs because the staffing deficiencies were not reported in state inspections.

          If he worked for me, I would fire him. He could take whatever solace he could find in the “other states” excuse.

          • re: ” to correct the very visible fact that they are endangered by widespread understaffing.”

            understaffing is a subjective phrase… who decides what is “understaffing” and what criteria is used?

            The lower star ratings indicate less staffing than other nursing homes but it does not appear to cause actions like investigations so what does beyond just someone saying it should?

      • Yeah, but this didn’t just start. It ain’t been good for awhile, and maybe it got worse, but it was called “warehousing Granny” for as long as I can remember.

  4. I did Jim. One or two stars for staffing is based on payroll metrics and so are the outcomes so what exactly warrants more/additional “inspections”?

    What would the additional inspections be looking for that was not already captured by the metrics?

    • Perhaps also this question. We know that CMS can and does withdraw Medicare and Medicaid funding. What are the reasons they would do that? Is it because of the “star” ratings or something else? Are nursing
      homes put on “probation” to see if they can improve?

      I’m just not seeing much in the way of specifics as to the reasons why a nursing home would actually have Medicare/Medicaid funding withheld or shut down all together. I DO SEE a red hand that signifies “abuse” but apparently even those nursing homes still continue to operate.

      (this was Oct 2019):
      ” Federal officials will soon affix a bright red “stop” hand icon next to facilities that have received recent abuse citations, the Centers for Medicare & Medicaid Services announced Monday afternoon.

      CMS unveiled the labeling plans as part of an unfolding five-pillar plan that includes improving transparency for consumers. Starting Oct. 23, the “Do not proceed” symbol will be placed next to facilities that have been cited for abuse, neglect or exploitation. Authorities call the open-palm display in a red circle “a consumer alert icon.”

      It will appear next to facilities that have been given a citation for abuse that led to the harm of a resident within the past year or cited for abuse that could have potentially led to resident harm in each of the previous two years.

      Mark Parkinson, president and CEO of the American Health Care Association, said the plan should be halted until there is more clarity.

      “We support transparency so that potential residents and their families can make an informed decision on care,” Parkinson said in a statement. “We appreciate CMS’ efforts to improve Nursing Home Compare but as we have previously suggested, we believe that CMS should create a standard and rational definition of both abuse and neglect and then report them separately. That would help provide consumers with the information that they need.”

      “In addition, CMS should add customer satisfaction to Nursing Home Compare because that is the best way for consumers to select facilities. It’s surprising that we can look for customer reviews of restaurants and hotels that we select, but that information isn’t available for nursing homes. We should have a way to let families and residents think of the facilities they are considering,” Parkinson added.

      Katie Smith Sloan, president and CEO of LeadingAge, called on CMS to “fix the survey system” before “adding this warning sign.”

      “Abuse and neglect must never be tolerated, in any setting. Our members support efforts to help consumers make the best choice possible when choosing nursing home care for their loved ones,” Smith Sloan said.

      “The abuse icon program in Nursing Home Compare, however well-intentioned, risks misleading consumers. It is built on the back of a flawed survey system, in which interpretations of regulations are notoriously inconsistent,” she added. “We need to fix the survey system before we start adding this warning sign. We want consistent application of regulations. We envision a system that allows flexibility to target resources where they are needed. LeadingAge members seek to work with surveyors, focusing less on punishment and more on consultation, training and continuous improvement. We all want the best quality care and quality of life for our loved ones.”

      The icon will be updated on a monthly basis at the same time as inspection results. CMS said the monthly updating will come quicker than current quarterly updates and ensures that nursing facilities “will not be flagged for longer than necessary if their most recent inspections indicate they have remedied the issues that caused the citations for abuse or potential for abuse and no longer meet the criteria for the icon.”

      “Through the ‘transparency’ pillar of our five-part strategy to ensure safety and quality in nursing homes, we are giving residents and families the ability to make informed choices,” CMS Administrator Seema Verma said.

      She said the added information is meant for “incentivizing nursing homes to compete on cost and quality.”

      So the point here is that even for abuse – apparently neither CMS nor the State might actually close the nursing home.

      If it works this way for “abuse”, is it this way for “staffing” also?

  5. There is this also:

    The Special Focus Facility (SFF) program is for nursing homes that have a history of poor care and may need increased oversight and enforcement. On Nursing Home Compare, SFF program participants are identified with a New symbol. More information on this program, including the list of facilities and candidates, can be found here Opens in a new window.

    I do not see Cantebury nor Heritage Hall on these lists but I DO SEE other nursing homes in Virginia.

    /https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/sfflist.pdf

    Jim were you aware of this SFF designation?

    • So much to unpack there.
      Yes they are designated Special Focus Facilities and put on probation if their inspection results are really bad. Those that are on probation are inspected at least quarterly until they improve or are decertified. If the situation found by inspection is so bad that “widespread imminent danger” is found they can be closed immediately and the patients transferred.
      As for the State Survey Agencies, I noted in my essay above that they have been put on notice by CMS that their will be additional focus put on their performance.
      “The performances of SSAs have been wildly inconsistent. This resulted in an October, 2019, CMS memo to the SSA directors that announced strengthened oversight of state agencies’ performance in nursing home inspections relative to measures included in the State Performance Standards System (SPSS). Virginia may prove to be a target of that oversight.”

    • Yes, in my research to populate a spreadsheet with which to make comparisons, the Envoy chain was one of the ones for which I loaded data. Envoy of Westover Hills is a SFF facility and its star ratings are masked.

      • Is Cantebury and Heritage Hall designated as Special Focus Facilities?

        Isn’t that what is supposed to kick off more inspections?

        How come Virginia has several nursing homes that are SFF but not Cantebury and Heritage Hall?

  6. I agree with you that, morally, we have a responsibility to care for seniors who are not capable of caring for themselves and to care for them in safe, clean, and medically adequate facilities.

    In your post, you frequently refer to Heritage Hall facilities as being understaffed. The basis for that charge seems to be that they habitually fell below the national average and were rated a 1-star.

    Virginia has no specific staffing standards for nursing homes. As I said earlier, that should be remedied, by legislation and regulation. However, under current standards, VDH could not “have taken action” against Heritage Hall for not meeting staffing standards. As for CMS standards, they seem fairly minimal, based on your accounting. Was there any indication that Heritage Hall violated any of those guidelines, such as, ” The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week”? That seems very minimal to me, but that is the guideline.

    You say “there was not a single inspection-related nursing services deficiency recorded for Heritage Hall that reflected nursing shortages.” But, from what you have listed as CMS guidelines, “nursing shortages”, i.e. falling below the national average, would not constitute a “deficiency” in terms of meeting CMS guidelines. Based on that, it would seem that VDH and Dr. Oliver would have had no basis for reporting a deficiency in that area. I agree that Heritage Hall operated facilities that were likely substandard, but that does not a “deficiency” in terms of Virginia regulations or CMS guidelines. That is the real disgrace. If anyone is to blame, it would be the Board of Health, and not just this one, but boards going back many years.

    • Dick, when VDH inspects nursing homes annually under contract to CMS for purposes of Medicare and Medicaid certification, they are acting under federal law and regulations. The regulations are found in CFR 488. You are right about Virginia standards, but they are irrelevant when VDH conducts federal inspections.
      The CMS payroll-based Journal (PBJ) system is fed auditable payroll information in daily reports by each nursing home participating in Medicare or Medicaid.
      VDH Office of Licensure and Inspection’s Division of Long Term Care conducts the inspections.
      State Medicare/Medicaid inspection teams are required by CMS to prepare for inspections by downloading and reviewing CMS data including PBJ data. There is a computer record generated each time that is done.
      The patients of nursing homes by definition require round-the-clock nursing care. VDH inspections are historically loath to find nurse staffing discrepancies. If staffing discrepancies are reported, corrective action – hiring – is required. The lack of such inspection discrepancy reporting is the direct reason that most Virginia nursing homes report below average or much below average staffing.
      It is so statistically improbable for 17 Heritage Hall facilities, 16 of which have self-reported below average or much below average nurse staffing in the 4th quarter of 2019, to have undergone 51 inspections over three years without a finding by inspectors of a single nursing discrepancy that it warrants an investigation.
      CMS is aware that some of the State Survey Agencies (SSAs) are falling short of their responsibilities. See my section on the Director of CMS warning SSAs that she is going to toughen the State Performance Standards System (SPSS).

      • I understand the VDH inspectors are under contract to CMS and thus are to inspect for compliance with CFR regulations. But, I have looked at the federal regulations in CFR and can find only one that speaks to the number of nurses that a facility must have. That one is 483.35 and says that there must be at least one registered nurse on duty 8 hours a day, seven days a week. All the other regulations speak to quality of care. There must be sufficient numbers on duty on a 24-hour basis in accordance with the residents’ care plans. Section 483.25 sets out conditions for quality of care such skin integrity, mobility, incontinence, accidents, etc.

        It seems to me that the federal regulations are concerned primarily with the quality of care provided residents of nursing homes. That is as it should be. If the regulations were limited to specifying staffing ratios or levels, a facility could meet those requirements even if the staff neglected the residents.

        I agree with you that the deficiencies listed in the inspections likely are due to insufficient staffing. And we should be like those in Lake Wobegon where every one is above average. But I cannot find any provision in the CFR regulations that would allow sanctions to be levied on a nursing home solely for having staffing below the national average.

        I am happy to hear that the CMS director has issued warnings to the states. Frankly, however, I am doubtful that the administration in Washington is going to tighten enforcement of regulations in any area.

        • re: ” allow sanctions to be levied on a nursing home solely for having staffing below the national average”

          It’s actually possible for a well-run facility to have less-than-average staffing but still deliver high quality care… you can actually see this in some of the star ratings…

          And that regulation is on purpose – to encourage cost-effective operations… to incentivize good care but cost-effective.

          When I look at the SFF aspect of CMS, it becomes clear that they hold off as long as possible to essentially drastic actions against nursing homes. They try to get the nursing homes to improve…

          In the end, for all the hew and cry over “onerous regulations” that come most often from Conservatives – right now, this administration is in the midst of trying to roll some of them back, to then go after VDH for “lax” regulation is a bit Jekyll and Hyde.

          If criticism was coming from across the spectrum regardless of political philosophy – it would have merit but when a lot of it seems to be coming from the opposing political folks – it gains an odor.

          I’ve just been a skeptic on this from the get go and I’m not any more convinced than I was before.

          Clearly, Jim knows a LOT…. and he does work hard on his essays… but I still have some doubts especially since we never really talked about SFFs early on.

  7. re: ” VDH inspections are historically loath to find nurse staffing discrepancies. If staffing discrepancies are reported, corrective action – hiring – is required. The lack of such inspection discrepancy reporting is the direct reason that most Virginia nursing homes report below average or much below average staffing.”

    what is a nurse staffing discrepancy? Is it falsification of the payroll data or some such? How is it discovered and investigated?

    Nursing homes can be one star on staffing and still NOT designated as a SFF.

    How does SFF fit into the staffing issues and why haven’t you mentioned SFF before? It seems to be a very relevant factor.

  8. Nursing staffing discrepancies are listed in the CMS Manual for inspectors. They are called tags. The tags for nursing staffing deficiencies include:
    F725 Sufficient Nursing Staff

    F726 Competent Nursing Staff

    F727 Registered Nurse 8 Hrs/7 days/Wk, Full Time Director Of Nursing

    F728 Facility Hiring and Use of Nurse

    Those are the tags that go in the left hand column of the inspection report. Corrective actions for those tags F725 and F727 must include additional nursing staff. The center column is used to explain what was found in the inspection led to the assignment of that tag. The last column is for the facility to list the corrective actions it intends to take to correct the discrepancy.
    I’ll give you the example for tag F727.
    The regulation states that unless a waiver is in place:
    – A facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week
    – The facility must designate a registered nurse to serve as the director of nursing on a full-time basis (35 or more hours per week). The Interpretive Guidance states that the DON requirement can be fulfilled by using two or more RNs so long as the roles and responsibilities for all RN staff serving as the DON are clearly defined and facility staff understand how the responsibilities are shared.
    – The director of nursing may only serve as a charge nurse when the facility’s average daily census is 60 or fewer residents

    Inspectors are to be aware of that regulation when inspecting nursing homes and they are required to prepare for the investigation visit by downloading PBJ data that can reflect violations and pick the lists of residents whose records they will review to look for evidence of such understaffing in care plans or in execution of care plans as well as hospital re-admissions and other data, all of which must be recorded by the facility. When they arrive for the inspection, the person with the primary responsibility for assessing staffing should go to those records and examine them. An F727 tag (or whichever) is assigned as appropriate. My whole study has shown a disconnect between PBJ data and inspection findings relative to staffing.
    As for SFF designations, Virginia only one of them and five candidates. My full investigation went to 9000 words, and that piece of information did not make the cut for this blog.

  9. Jim – what is the relationship with these “tags” to SFF?

    How does a nursing home get designated as SFF? What factors?

    And why is Cantebury and Heritage Hall which seem to have staffing issues not designated as SFF?

  10. Taking rest of day off.

  11. You guys do realize that you are having these long discussions with the WRONG people, don’t you?

    You should be telling all of this to the wife. She’s the one who’s gonna stick you in one of these places. If she thinks the “F” on the restaurant door stands for “Fine Dining”, you might be in trouble.

  12. I HIGHLY recommend that EVERYONE visit a nursing home, maybe 2 or 3 and it ought to convince you that you’ll never aspire to end up there.

    There are a lot of ways to end, this is not a good way.

    • “Well, I’ve good news and bad news,” the doctor said. “The bad news is that you have stage 4 renal cancer. The good news is that it won’t bother you for long.”

      Maybe nursing homes are the same; a short stay in a 1 star versus a long stay in a 5 star.

  13. this is like a short stay extreme purgatory versus a long stay – just ordinary terrible purgatory.

    Don’t get me wrong – the folks that work there work their butts off TRYING to do what they can do but in the end – it’s an ignoble way to end one’s life.

    And the real irony is – that medical “science” is responsbile …without it – many would check-out early – just like the “open it up now” folks do advocate!

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