Turnover is a large issue in adequate staffing and the Quality Improvement Program seeks to address one area which leads to turnover, staff dissatisfaction. One thing that leads to dissatisfaction is a lack of support and poor management at facilities. In addition to offering mentorship and support to staff members, we hope this program can also provide support and training to management at facilities. Creating better job satisfaction, and therefore retention of quality employees is to the benefit of the facility, staff, and residents.

We support programs that lift low-performing facilities’ staffing hours and improve the care provided, but we have concerns that a value-based purchasing program when implemented might not achieve this goal. To protect against this, we hope this program is reviewed closely to make sure that quality is improving across the board. Additionally, we would suggest implementing peer grouping which takes into account social factors that affect health when evaluating which facilities meet requirements and is supported by MACPAC as a way to address issues with health inequity. Peer grouping is a mechanism that CMS currently uses in a Hospital Readmissions Reduction Program and that has been modeled in several redesigned payment programs. If patients with higher social risk have worse outcomes, then the program should take this difference into consideration when assigning rewards/penalties to providers. This helps alleviate the concern that facilities with low-risk patients and/or high private pay/rehab patients will receive the rewards and facilities that have high risk primarily Medicaid populations will not.

We agree that acuity is a key consideration when ensuring nursing home staffing is sufficient to meet resident needs. As drafted, 2022 legislation references acuity standards as determined by CMS. But CMS has never promulgated required minimum staffing standards for nursing homes, including acuity standards. There are CMS regulations requiring sufficient staffing be in place to care for residents & CMS identified recommended minimum hourly thresholds for sufficient staffing. Federal CMS regulations require nursing homes that participate in Medicare & Medicaid have sufficient nursing staff with the appropriate competencies & skill sets to ensure residents' safety & attain or maintain the highest practicable physical, mental, & psychosocial well-being of each resident. CMS identified minimum staffing thresholds: Hourly staffing minimums would be the best way for Virginia to offer some assurances to residents, families & facilities that a facility is attempting in good faith to comply with CMS recommendations. For example, a recent report by The National Consumer Voice for Quality Long-Term Care highlights that Virginia is one of only 18 states remaining with no direct care minimum staffing requirement. Most states incorporate hourly staffing standards when they address this issue. Numerous studies have found a direct correlation between the quality of resident care & the number of nursing staff. Better staff to resident ratios improves care as seen in reduced incidence of pressure sores, lower use of physical restraints, & fewer hospital admissions. Nursing facilities certified to participate in Medicare & Medicaid must provide ‘sufficient’ staff to care for the residents and resident acuity is an important part of this obligation. The sufficient staffing requirement is detailed at C.F.R. 42 CFR § 483.35: The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.70(e). Acuity considerations must be taken into account for facilities to meet their obligations to “ensure residents' safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.” But for ease of operationalizing this new policy & for uniformity in monitoring the standards, we believe this standard should be implemented through hourly minimum standards. Using an acuity-only standard would require the development of a wholly new standard which could muddy the waters in a process that should be as transparent as possible. Facilities see fluctuating resident populations & changing resident acuity levels & needs & must be able to rely on easily identified thresholds that can be publicly communicated to residents & families. Additionally, family members trying to understand whether a facility is properly caring for a resident will be better served by understanding the staffing standard requirements in terms of hours of care per resident per day as a clear metric to determine if the facility is close to or is meeting the sufficient staffing standards on any given day.

Comments Document

Please see the attached letter submitted on behalf of Virginia Hospital & Healthcare Association.

As an older Arlington resident, I am writing to express support for the adoption of staffing standards in Virginia nursing homes. The Health, Welfare and Institutions (HWI) Committee has a unique opportunity to further address the issue of nursing home staffing standards. Although HB 330 and HB 646 did not make it out of Committee, HWI approved carrying over the bills to the 2023 General Assembly session. In addition, a study group is being impaneled to further study the nursing home staffing standards issue with the goal of passing legislation next year. This is on the HWI agenda at the meeting on April 27, 2022. Please consider the needs of Virginia's most vulnerable residents and support legislation to adopt nursing home staffing standards. Thank you. Joan McDermott 3601 N. Kensington St. Arlington VA 22207 703-536-9289

Comments Document

Please find attached a LeadingAge Virginia position statement on nursing home staffing legislation.

The State may not be able to fully evaluate whether corporate-owned nursing homes are properly utilizing government funds that are provided for the direct-care of its residents. One method would be to require nursing homes to submit annual consolidated financial reports to the appropriate state agencies. The report could include, but not be limited to, data from all corporate owners, operating entities, license holders and all related companies that have an ownership or controlling interest and/or provides any service, facility, or supply to the nursing home. The report could allow the State to determine: 1) How much of Medicare, Medicaid, Provider Relief Fund or other government payments are spent on direct-care. 2) Identify any cost savings or funds that could be put to better use of government disbursements and nursing home expenditures. 3) Whether the nursing home industry’s stated need and request for increased government payments are merited. I recommend the State should require corporate entities that own or have a controlling interest in a nursing home to prepare and submit an independently certified annual consolidated financial report. (This requirement could be applicable to all skilled nursing facilities in Virginia.)

My review of the Virginia Department of Health’s (VDH) nursing home licensure process indicates that the State does not require the identification of healthcare corporations, private equity or other corporations that have an ownership or controlling interest in nursing homes applying for a new or renewed license. To date, though my research continues, I have determined at least four private equity corporations own approximately 39 of 44 health care corporations which, in turn, own or operate 170 of the 287 nursing homes operating in Virginia. Another private equity firm may be in the process of acquiring a healthcare corporation that operates at least five nursing homes. Not one of the health care corporations or private equity firms are listed on the most current applications for the 170 nursing homes I have identified to date. Nor does the licensure process require corporations with ownership or controlling interest to identify any companies they may own that provide any services, supplies and facilities to the nursing home seeking license. It does not appear that VDH and other state agencies are able to monitor the impact of corporate ownership on the administrative and operational policies and practices, quality performance and financial efficacy of nursing homes. This includes determining how much of federal and state funds are spent on direct-care and not for other corporate purposes. Further, the application process is not automated; a nursing home applicant must download the application form, fill it in and forward it to VDH. I recommend the State of Virginia require all nursing home applications (initial and renewal) to identify all corporate entities that have an ownership or controlling interest in the nursing home and their companies that provide any services, facilities, and supplies to the nursing home. (This requirement could be applicable to all skilled nursing facilities in Virginia.) And I also recommend that VDH automate its licensure application process.

Comments Document

Please support and find a way for Virginia to have staffing standards in its nursing homes.

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As a licensed professional counselor I urge you to pass and enact this compact which would allow counseling to occur across state lines in all participating states. I personally hold a license in both Maryland and Virginia so that I can see clients from both states. This is an added pressure to my already high pressure job. Add to that 2+ years of pandemic and I’ve just about had it! Then to see this possibility of progress just stricken from the House ballot it makes me want to quit! Counselors everywhere are feeling the same. This does not bode well for the future of mental health. Please read and enact this compact which could help us immensely. Thank you