RICHMOND, Va. — Virginians hoping to finally see a minimum staffing standard imposed on the state's nearly 300 nursing homes are expressing disappointment after a bill that initially aimed to put such a requirement in place no longer includes any enactment of an actual standard.
“Disappointment. Definitely frustration," nursing home resident advocate Joanna Heiskill said about her reaction to the change. "It's very hurtful because it looks as though our government in Virginia does not care enough."
Del. Rodney Willett (D-Henrico) originally proposed a staffing standard, and it was advancing through the General Assembly with bipartisan support. But by the time the bill passed the House of Delegates, its language had been reduced to direct a study of "the workforce in Virginia nursing facilities."
The study would be completed by the Joint Commission on Health Care which previously produced a study on this same issue in 2021.
"We have so many studies. We've been studying this for years. This isn't a new problem," Heiskill said. “It just snatched away the hope that families had for there to be some inroad toward change and justice.”
Virginia is in the minority of states without a staffing minimum and ranks among the bottom 20% of states when it comes to federal staffing ratings.
Stakeholders including Heiskill, who served on Governor Youngkin's nursing home advisory board and says her mother suffered in a facility, often equate higher staffing levels to better quality of care.
“It's just basic common sense. If you have enough staff, then you can take care of residents properly," Heiskill said.
So, what changed?
“What we're really running into is what we're running into in multiple areas, and that's the budget," Delegate Willett told CBS 6 in an interview. "The bottom line is, there is a huge funding gap, one, created by things the former governor did not fund in his budget, and then two, the incredible impacts coming from Washington."
Willett explained it's a tight year for funding, and the staffing minimum would have brought increases in state Medicaid reimbursements. It's not clear by how much, but Willett estimated the annual cost would have been significantly less than $20 million.
“Is there any way of implementing this standard without having to increase Medicaid costs?” reporter Tyler Layne asked.
"Unfortunately not," Willett said.
His original bill would have imposed a minimum average of 3.25 acuity-adjusted total nurse staff hours per resident per day, which was a recommendation from the 2021 Joint Commission on Health Care study. Amid some industry pushback, the standard was then lowered to 3.08, at least for the first several years of implementation, to align with a previous attempt in 2023 to set a standard in Virginia. Ultimately, the bill then was turned into a study after going through a budget committee.
“As you know, there already was a study done in 2021 and that produced the recommendation of 3.25 as a minimum, which you initially introduced with this bill. So why do we need another study just a few years later?” Layne asked.
“That's a good question, and I think it's been driven by the fact that the study was done when we were in covid, coming out of covid. There's some trends that actually look better. Some facilities are doing better and they're recruiting. Others say there are still challenges. So we're trying to just make sure we've got the most accurate data possible," Willett said.
The Virginia Health Care Association (VHCA), which represents nearly all of the state's nursing homes, most of which are for-profit, said there has been "substantial recovery" in the workforce since the pandemic, but that "significant challenges" persist in that various healthcare providers compete for a limited supply of nurses and direct care professionals.
"VHCA-VCAL has been working with the General Assembly for a number of years to develop a commonsense and achievable staffing standard for nursing homes. Since nearly 7 in 10 nursing home residents rely on Medicaid to cover the cost of their care, we’re extremely grateful that Del. Rodney Willett and the General Assembly acknowledge that it is critically important that any staffing mandate be funded," VHCA spokesperson Amy Hewett said about the evolution of the bill.
Meanwhile, LeadingAge Virginia, which only represents non-profit providers, expressed concern over the changes to the bill and hopes the staffing standards can be added back in as the legislation now works its way through the Senate.
"It is concerning that a House budget committee amended the bill to remove the staffing standards, as clear and consistent expectations are essential to elevating quality. We know staffing is the strongest indicator of quality care, and the commonwealth has a responsibility to take every possible step to ensure nursing homes have the workforce necessary to meet residents’ needs and ensure their safety. We hope that a minimum standard in the Senate will be reconsidered, including the 3.08 hours that was agreed upon during the 2023 Virginia General Assembly session," said Dana Parsons, the organization's vice president and legislative counsel.
LeadingAge Virginia said its members, on average, maintain 4.3 hours of total nurse staff per resident per day, which well exceeds the proposed minimum. Non-profit providers generally have better federal quality and staffing ratings, and the state's long-term care ombudsman Joani Latimer, whose office responds to resident and family member complaints, said there's "a very clear difference between those that are for-profit facilities and the not-for-profit facilities."
“It's just the bad apples that are giving the industry a bad name, which is why, for example, the nonprofits are stepping up so loudly to say, 'We want standards,'” Willett said.
“What would you say to someone who feels let down that this isn't moving forward?” Layne asked.
“I’m right there with them, me and other legislators. We all want to do better. We all want the system to do better. So the money is the hurdle right this minute," Willett said.
He added there are a number of other pieces of legislation that aim to bring accountability and transparency to the industry, including one of his own bills that would require operators to provide more information to the health department during an ownership change. It would also direct the health commissioner to review an operator's history when determining whether to approve an ownership application.
Further, Willett said there may be an opportunity for the state to increase its oversight of how facilities have been spending the Medicaid dollars they're already getting.
"You're going to see more accountability. You're going to see more transparency. And as I said, there has never been a brighter spotlight on what's happening here. So maybe folks were able to sort of stay under the radar, cut some costs, cut some care. That's not going to be tolerated going forward. And a lot of these facilities, they are getting money, additional money, through the [Department of Medical Assistance Services]- more scrutiny through them," Willett said. "It's a lot of money, and I think right now, it's a little bit of an honor system, and for a lot of operators and facilities, that's fine, but there are others we really need to verify what they're doing,"
But Heiskill said she's tired of the perceived delays and inaction from politicians.
“Don’t cause nursing home resident so suffer," Heiskill said. "They're in a position now where they are totally vulnerable, and they need their government to step in and say, 'Hey, we're not going to allow this to happen to Virginians.' So I would say, straighten up and get it done.”
The Board of Health had already initiated regulations that would implement an enforceable 3.08 staffing standard in response to legislation passed by the General Assembly in 2023. However, the promulgation of that regulation was paused due to a conflict between state and federal law that has now been resolved.
When asked whether that regulation could proceed, the Virginia Department of Health said it "is reviewing its statutory authority in this matter."
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