RICHMOND, Va. — Delegate Rodney Willett (D-Henrico) is pushing to set a nursing home minimum staffing standard in Virginia, something he said is long overdue. But there was mixed feedback on what that standard should be, and Willett ultimately agreed to lower his proposed staffing requirement, at least for the first several years of implementation.
“This is a bill that does something we've been trying to do in Virginia for a long time," Willett told a General Assembly subcommittee on Tuesday during a hearing on his bill. "There's a long history here in terms of having requirements, not having requirements."
He's referring to when the General Assembly passed a minimum staffing standard in 2023, but it never took effect because the federal government attempted to impose a more rigorous staffing requirement that was ultimately repealed. So Willett said his legislation would "put the ball back with the state."
Federal data shows that Virginia currently ranks among the bottom 20% of states in the country when it comes to average staffing ratings, which the federal government calculates using quarterly staffing reports and rates of turnover.
Stakeholders often equate higher staffing levels to higher quality of care. The state's long-term care ombudsman Joani Latimer, who said her program is overwhelmed by consumer complaints that are growing more complex in nature, said poor staffing is the root cause of many of the problems her office confronts.
“We are constantly getting concerns brought to us by residents and their families in terms of just basic daily care needs, and that just requires enough people on the floor to provide basic hygiene, nutrition, toileting, help with day to day activities, ensuring individuals in nursing homes are supervised and they can avoid accidents that shouldn't be happening," Latimer said.
But resolving disputes in facilities is getting harder for her staff, she said.
“In many ways, it's become more difficult to get resolution to problems, partly because we don't necessarily get a lot of cooperation when we're saying, 'Let's get sufficient staffing here,'" Latimer said.
As initially proposed, Willett's bill would have required nursing homes to provide an average of at least 3.25 acuity-adjusted hours of total nurse staff per resident per day.
For comparison, in 2021, Virginia's Joint Commission on Health Care recommended a 3.25 standard to target the lowest staffed and poorest performing nursing homes. In 2023, the General Assembly approved a 3.08 minimum standard. In 2024, the federal government intended to impose a now-overturned minimum of 3.48.
However, following opposition from the industry, Willett said he compromised and lowered his proposed minimum to 3.08 which would take effect in 2027. It would later increase to 3.25 in 2031. Willett said the phased approach would give struggling nursing homes ample time to get to "where we need to be."
“We really hate to see that kind of delay. I mean, I don't think our residents can wait until 2031," Latimer said. "We certainly support the efforts going forward. We wish this were higher. We wish we had at least gotten to the level that the Joint Commission study a couple years ago carefully substantiated that would make a difference in some of our most low performing facilities."
Joanna Heiskill, a resident advocate on Virginia's nursing home advisory board, expressed a similar sentiment, saying she supported the 3.25 minimum which "more closely reflects what residents need for safe and dignified care."
"While I am disappointed by the reduction to 3.08 hours and the extended implementation timeline, I recognize this version as a step forward rather than a rejection of reform. What’s critical is that the bill acknowledges current staffing levels are inadequate and establishes a path toward improvement," Heiskill said.
Jared Calfee with AARP Virginia similarly said he wished the General Assembly was moving forward with the higher staffing standard and noted non-profit nursing homes, which make up about 22% of facilities in the commonwealth, tend to already provide adequate staffing.
“I would point out that our non-profit facilities are, by and large, already exceeding that standard, and it is primarily our corporate-owned facilities that want to keep this number as low as possible," Calfee said.
Latimer agreed, saying, “Generally speaking, it's fair to say that we can track levels of staffing and see a very clear difference between those that are for-profit facilities and the not-for-profit facilities."
LeadingAge Virginia, which represents only non-profit nursing homes, did not take an official stance on Willett's bill, but said in a statement, “Staffing is the greatest proxy for quality of care. According to CMS Five-Star data, our not-for-profit members maintain higher nurse staffing levels, which are associated with better outcomes for older adults. We look forward to engaging with the Joint Commission on Health stakeholder group and support continued workforce investments to help nursing homes recruit and retain high-quality staff.”
Meanwhile, the Virginia Health Care Association, which represents for-profit and non-profit nursing homes, said it was concerned about Willett's original version of the bill because it included a higher minimum than the 3.08 standard the General Assembly passed in 2023. During Tuesday's hearing, the organization's lobbyist Scott Johnson spoke in favor of the changes to the bill.
“The workforce— we don't have enough, but we need more funding from the General Assembly to pay the workers we have and to be able to retain them," Johnson said.
As currently written, the bill allows for several exceptions to the requirement and gives facilities found to be in violation of the standard multiple opportunities to course-correct before facing sanctions. It further shields nursing homes from penalties if the state does not provide enough Medicaid funding to cover staffing costs. Additionally, it states the prominent industry association, the VHCA, shall be consulted along with other groups when the regulations are being put into effect. The VHCA said it was common for organizations to be specifically named in stakeholder efforts.
The bill also directs the Joint Commission on Health Care to study the possible requirement for facilities to have a registered nurse onsite 24/7 and to allow non-nurse staff to be included in the calculations to meet minimum staffing standards.
"Nursing home patients sometimes are on ventilators, and so respiratory therapists are providing care. That care needs to be counted in the equation. Medication aides, other people like that," Johnson said.
Ultimately, the General Assembly subcommittee had no further questions or comments regarding the bill during Tuesday's hearing and voted unanimously to advance it forward in the legislative process.
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