RICHMOND, Va. — The state government office responsible for making sure healthcare facilities are running properly hasn't been running properly itself, according to an internal report obtained by CBS 6.
A study examining staff satisfaction among medical facility inspectors revealed "significant issues within the work environment," negatively impacting their quality of work.
Last week, the Virginia Department of Health (VDH) confirmed a leadership shakeup within its Office of Licensure and Certification (OLC). The OLC licenses facilities including hospitals and nursing homes and is supposed to regularly inspect them for compliance with care and safety standards. The office is also responsible for responding to and investigating consumer complaints submitted by members of the public.
Watch: Leadership changes impact VDH office responsible for inspecting nursing homes, hospitals
As CBS 6 has reported in previous investigations, the OLC has struggled to keep up with a skyrocketing increase in nursing home complaints and ranks next to last in the country for nursing facilities overdue for routine inspection, which should occur at least once every 15 months. According to federal data, 68% of Virginia nursing homes are overdue for inspection while the national average is 17%.
The office is now undergoing leadership changes, with former OLC Director Kim Beazley moving to a new role as a senior policy advisor for VDH. Acting Director Jim Jenkins is taking over as the agency searches for a permanent replacement. One of the focuses moving forward, according to the agency, will be “enhanced recruitment and retention efforts of Medical Facility Inspectors.”
State Health Commissioner Dr. Karen Shelton acknowledged in a public meeting last month that "low staffing has been a factor and a large problem as we look to ensure the appropriate oversight for nursing homes.” As regulators have noted an "overall decline in the care being provided to residents," Shelton said nursing home accountability is a priority for the agency moving forward.
A recently obtained March 2025 Culture Assessment, Response, and Engagement (CARE) Team study of the OLC may shed some light on how much work needs to be done to strengthen its oversight and enforcement efforts.
At the time of the report, over 50% of positions were vacant, meaning "most functions in the office are not running properly."
The assessment was "requested and initiated by VDH senior leadership in the Central Office in response to concerns raised regarding OLC from multiple internal sources," according to agency spokesperson Maria Reppas. The CARE team solicited feedback from staff in all levels to come up with its findings, and the response rate was around 40%.
Study findings
While the report did note some positive findings such as staff being highly satisfied with their relationship with supervisors and a strong commitment to the mission of public health, there were many weaknesses and threats identified.
According to the report, senior leaders including the director, deputy director, and division directors were seen as "unapproachable, overly critical, and retaliatory." Staff reported feeling undervalued, underappreciated, overworked, underpaid, and met with harsh criticism when mistakes occur.
There is no specific onboarding process for OLC, meaning staff "must figure out job responsibilities on their own and are reprimanded for not knowing certain tasks, despite never being trained or given guidance." Staff felt that management has been "hammering hard with accountability" but not providing coaching or training.
"Some of these teams do seem to be underperforming, supporting the need for accountability," the report said. "However, it is important to note that staff report they do not have the training, resources, and procedures necessary to successfully do their jobs."
A lack of adequate training was a common theme throughout the report. The OLC's training manager position was unfilled which was "substantially impacting office operations and [medical facility inspectors'] quality of work." The vacant training role raised concerns that staff "are lacking crucial information and skills."
Inspectors reported not being allowed to attend Centers for Medicare and Medicaid Services (CMS) trainings, despite the trainings being required for the position. They also reported not being allowed to attend CMS conferences and that they were not given time to prepare for the CMS exam that inspectors must pass to become a federally certified inspector. Of note, CMS regulations and requirements have a heavy influence on the duties of a facility inspector, and these positions are mostly funded through federal dollars.
The report stated there was a "lack of standardized procedures" for medical facility inspections leading to "inconsistent practices." Additionally, facilities were assigned to inspectors "without consideration for location, facility type, or time to complete" the inspection, and complaints were assigned separately rather than assigning complaints to the staff member already visiting the facility in question.
Staff compensation was reported to be inadequate, and employees said pay was their primary reason for considering leaving.
Other concerns identified in the report included:
- Tenured staff do not have access to subject matter experts to provide reliable support and help them with latest knowledge in the field
- Critical positions have remained vacant for years, affecting staff morale
- New employees are being hired without proper vetting
- There's a substantial backlog of work that could take years to address
- Medical facility inspectors are required by CMS to be a licensed practical nurse, but "this may not be happening in all positions"
- Due to an increase in complaints, staff want a dedicated complaints supervisor role
- There's no formal retention plan in place despite high turnover
When asked whether the findings described in the report have impacted the accuracy, credibility, and timeliness of facility inspections, Reppas did not provide a direct answer but said, "The CARE study is a tool used internally to assess the culture of a work unit and to identify opportunities for improvement, which can lead to improved recruitment and retention as well as an improved environment where staff have the necessary tools and resources, including appropriate staffing levels, to perform their jobs effectively."
In May, OLC leadership submitted a response to the report, outlining goals for improvement which included leveraging HR support to reduce vacancies, implementing a preceptor, orientation, and training plan, increasing employee engagement and satisfaction through culture and communication strategies, reducing the turnover rate to 10%, and removing obstacles that interfere with operations.
"Former Director Kim Beazley delegated the creation of this plan to the now-Acting Director James Jenkins, who created an action plan that included SMART goals and coordinated with the OLC leadership team for feedback. This action plan focuses on leadership engagement, recruitment, orientation/onboarding, communication/culture, and retention. These goals were further refined after review by members of the VDH Senior Leadership team. OLC and VDH senior leadership meet regularly to assess progress towards these goals and to identify needed resources," Reppas said.
The response stated medical facility inspectors would be added to VDH's critical, hard-to-fill positions and hiring incentives such as sign-on bonuses would be offered. Leadership also came up with ideas to boost morale including incorporating an OLC suggestion box, quarterly celebrations, and regular one-on-one meetings with supervisors.
To address retention, leadership planned to introduce pay raises, request a salary-related budget amendment in 2026, and support attendance at training conferences.
Many of these efforts are already underway, according to Dr. Shelton's recent presentation to the Joint Commission on Health Care.
"We're excited to be able to work at multiple solutions to attract people, hiring our medical facility inspectors to our agency. We have some short and long term goals as far as these hiring parameters, and we see a significant opportunity here as far as what we can do to provide solutions," Shelton told lawmakers during the meeting.
According to the CARE response, a re-assessment will be requested for September with a goal of higher participation from staff.
When asked whether the concerns identified in the report had anything to do with the recent leadership changes, VDH declined to answer citing personnel information exempt from disclosure.
This is a developing story. Email the CBS 6 Newsroom if you have additional information to share.
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