Bacon's Rebellion

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Who Is Tommy East?

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sherlockj
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Tommy East

James C. Sherlock

Tommy East sits as the Nursing Home Industry representative on the Virginia Board of Health. He is the President & CEO of Heritage Hall Healthcare and Rehabilitation Centers, an operator of nursing homes headquartered in Roanoke.

In 2014, he was appointed by Governor McAuliffe to serve on the Commonwealth of Virginia Board of Health. In 2018, he was reappointed by Governor Northam.

East has served on the Board of Directors and the Executive Board for the Virginia Health Care Association (Nursing Homes). The Virginia Healthcare Association over the years has contributed more than $2.5 million to candidates and PACs in Virginia.

Medicare Nursing Home Compare data and the state records maintained by Virginia Health Information were last updated on March 30, 2020, from facility payroll reports. In those data, 42 of Virginia’s 286 Medicare and Medicaid long-term care facilities reported one-star (much below average) staffing levels. More than half of the 286 were rated much below average or below average.

Mr. East is well versed in nursing home staffing shortages. Heritage Hall operates 17 nursing homes in Virginia. Of those, current Medicare staffing ratings show:

• one is rated average in staffing;
• nine below average; and
• seven much below average.

As but a single example, Heritage Hall Blacksburg is currently rated one star (Much Below Average) for staffing by Medicare. Registered Nurse (RN) hours per resident per day at the Blacksburg facility is a tick worse than that of COVID-19 tragedy-stricken Canterbury Rehabilitation and Health Care Center in Richmond. The Medicare staffing ratings for the two facilities are shown below. Patients are in nursing homes specifically because they need care supervised and delivered by registered nurses (RNs). First quarter 2020 payroll reports showed that each offered only 1/3 of the RN hours per resident per day compared to the national average.

Nursing home residents now are locked in and allowed no visitors. Anyone with knowledge of the system and human nature will tell you that care can deteriorate when a patient is not visited regularly.

Governor, you and your Health Commissioner have statutory authority and responsibility for the health and safety of Virginia’s nursing home residents. Take action.

Please direct your Health Commissioner immediately to dispatch his inspectors to the 42 Virginia nursing homes reported much below average in staffing on March 30. Take immediate action against the ones that are dangerously understaffed.

42 CFR 488.301 “A State must establish, in addition to termination of the provider agreement, the following remedies or an approved alternative to the following remedies for imposition against a non-State operated NF:

(1) Temporary management.
(2) Denial of payment for new admissions.
(3) Civil money penalties.
(4) Transfer of residents.
(5) Closure of the facility and transfer of residents.
(6) State monitoring.”

Start the inspections with Mr. East’s Heritage Hall facilities.

Remove Mr. East from the Board of Health

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Comments

59 responses to “Who Is Tommy East?”

  1. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    The silence is deafening. As it should be.

  2. CrazyJD Avatar
    CrazyJD

    Most of you know that I don’t like much of what government does, and generally they do it very badly. There are a couple of exceptions, namely, those things that, structurally, the private sector cannot do: Police, fire, environmental protection (the latter by a rational entity not driven by agenda) But additionally, I think it may be a legitimate function of government see to the protection of those citizens who are truly unable to protect themselves. This would include the mentally ill and those in nursing homes. We can argue about who foots the bill, but generally speaking it is a legitimate governmental function to regulate nursing homes to the extent necessary for the protection of residents. To me, it’s clear that this is not being done in Virginia.

  3. V N Avatar
    V N

    Agreed.

  4. James Wyatt Whitehead V Avatar
    James Wyatt Whitehead V

    Contact information for the Virginia State Board of Health can be found here:

    http://www.vdh.virginia.gov/commissioner/administration/board-of-health/virginia-state-board-of-health-membership-roster/

  5. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    The silence is deafening. As it should be.

  6. CrazyJD Avatar
    CrazyJD

    Most of you know that I don’t like much of what government does, and generally they do it very badly. There are a couple of exceptions, namely, those things that, structurally, the private sector cannot do: Police, fire, environmental protection (the latter by a rational entity not driven by agenda) But additionally, I think it may be a legitimate function of government see to the protection of those citizens who are truly unable to protect themselves. This would include the mentally ill and those in nursing homes. We can argue about who foots the bill, but generally speaking it is a legitimate governmental function to regulate nursing homes to the extent necessary for the protection of residents. To me, it’s clear that this is not being done in Virginia.

  7. V N Avatar
    V N

    Agreed.

  8. James Wyatt Whitehead V Avatar
    James Wyatt Whitehead V

    Contact information for the Virginia State Board of Health can be found here:

    http://www.vdh.virginia.gov/commissioner/administration/board-of-health/virginia-state-board-of-health-membership-roster/

  9. Nancy_Naive Avatar
    Nancy_Naive

    Could be worse. Could be that his only experience was breeding labradoodles, or Arabian horses.

  10. Nancy_Naive Avatar
    Nancy_Naive

    Could be worse. Could be that his only experience was breeding labradoodles, or Arabian horses.

  11. SGillispie Avatar
    SGillispie

    Thank you again for posting with unassailable facts and documented conclusions and recommendations.
    This should be the standard for BR as opposed to the scorch and burn, mock and smear writings encased in scornful, supercilious, opinionated, and shallow rhetoric by some of the other authors who appear here.

  12. SGillispie Avatar
    SGillispie

    Thank you again for posting with unassailable facts and documented conclusions and recommendations.
    This should be the standard for BR as opposed to the scorch and burn, mock and smear writings encased in scornful, supercilious, opinionated, and shallow rhetoric by some of the other authors who appear here.

  13. Peter Galuszka Avatar
    Peter Galuszka

    Interesting report but not surprising. It’s been this way for many years. The issue is how to regulate and for private firms, how to comply and get the trained staff they need. Not sure the “magic” if the free market works here.

    1. sherlockj Avatar
      sherlockj

      Peter, I am not asking for market magic. I rather request the state use its authority and responsibility to take actions.
      (1) Temporary management.
      (2) Denial of payment for new admissions.
      (3) Civil money penalties.
      (4) Transfer of residents.
      (5) Closure of the facility and transfer of residents.
      (6) State monitoring.”
      Take Mr. East’s Heritage Hall. Please (old joke). The staffing record of Heritage Hall nursing homes suggests a pattern of non-compliance. Heritage Hall has been doing this long enough that it must be presumed profitable. Transfer enough residents from the homes staffed “much below average” to other long term care facilities or hospitals to ensure that the remaining patients get sufficient staff attention. Take temporary state management control of those facilities. Force a sale in lieu of closure or close the worst of them. I think the market would indeed “work its magic” when it noted that major investments in nursing homes are indeed at risk. The banks who hold debt from these enterprises will do the rest.
      If the state needs to raise Medicaid payments to nursing homes or open state-run nursing homes, do it, but it is not clear without access to tax returns of existing for-profit facilities that money is the issue.
      We have a statewide nursing shortage, so take action to fix that as well. The quickest answer is to recruit RNs in foreign countries. Virginia already participates in an international nurse recruiting program through CGNFS International. Healthcare workers are exempt from Mr. Trump’s move to slow immigration. Governor Northam needs to press this button pretty hard.
      To provide more detail, CGNFS is a one stop shop for international registered nurses. Virginia’s requirements are that RN applicants for initial licensure or professional endorsement either:
      1. Complete the CGFNS Certification Program; or
      2. obtain a Credentials Evaluation Service (CES) Professional Report, both through CGNFS; and
      3. Demonstrate English language proficiency.

      CGFNS VisaScreen® Visa Credentials Assessment Service is a comprehensive screening service for healthcare professionals seeking an occupational visa to work in the United States.
      Applicants who successfully complete CGFNS VisaScreen® receive an official ICHP Certificate for the VisaScreen. This certificate satisfies the United States Federal screening requirements.
      CGFNS International is approved by the United States Department of Homeland Security (DHS) to validate the credentials of nine foreign healthcare professions for occupational visas, of which CGFNS is the only organization to validate seven of those professions.

  14. LarrytheG Avatar
    LarrytheG

    Yep. In terms of political money – go to VPAP to see who gets money from Virginia Healthcare Association. You’ll see that they do like a lot of such organizations – both sides of the aisle get it.

    Next – On the right, including the Trump administration right now, they typically work to get rid of regulations on the premise that they drive up costs.

    So you have this situation where the argument is that regulation drives up costs – but at the same time the nursing homes are condemned for inadequate staffing that directly relates to the cost of having adequate staffing.

    Then, one more step, when ratings for staffing levels go down, then use it to go after political opponents which is what we see here with Mr. SGillispie routing them on.

    One would think that, no, you can’t have it both ways – i.e. lobby to remove regulations that add costs then at the same time go after the same nursing homes for cost-cutting staff reductions – and then go after the Governor demanding “investigations” and sanctions.

    This is how partisan politics works these days.

    Across the country – from New York to Washington State to Texas and Florida, nursing homes are all pretty much having the same issues in large part because nursing homes, as currently operated and regulated are not designed to operate with regard to dealing with the corona virus.

    So, rather than playing a political blame game like we see here, what would be advocated for reforms?

    Do we hear from the critics here in terms of what should be done to increase staffing? Nope. Because that would increase costs.

    What exactly is wanted? Oh.. we want cheaper nursing homes with more staffing, right?

    Want to increase regulation dictating more staffing? Is that a recommendation? Nope.

    so what is this? what is this really about?

    It’s not about calls to increase staffing…. It’s not about the State requiring staffing inreases or moving patients to less crowded nursing homes or any of that.. nope.

    nope.. it’s about assigning blame and coming from conservatives/GOP and aimed at a Democratic Gov.

  15. sherlockj Avatar
    sherlockj

    Your contention that saving sick and inform old people from the documented lack of nurses to care for them is somehow political does you no credit. I would hope that everyone would get behind this cause.
    We don’t need to increase regulation. More than half of Virginia’s nursing homes have documented substandard staffing under current regulation. It is enforcement we seek.
    As for solutions, see my note to Peter above regarding recruiting foreign nurses.

    1. LarrytheG Avatar
      LarrytheG

      Another political ploy – ” oh the poor victims”. 99% of this is about assigning blame , NOT helping those victims.

      Regulation that required increased staffing was gutted by Trump and now the claim is we need better “enforcement”. That dog don’t hunt. It’s totally disingenuous. “enforcement” of what? regulations that have been loosened? Are you going to hire at taxpayer expense more folks to do that and more staff to take actions against nursing homes?

      when you take away the regulation, what exactly are you going to “enforce”?

      re: recruiting foreign nurses? REALLY? Doesn’t that run counter to the idea of jobs for Americans and pay them a fair living wage? We’re gonna to use more immigration for cheap labor?

      When I see a fair and balanced narrative here, I’ll get off your case. Until then, I’m going to point out when it is political and partisan.

      BOTH sides – Dems and GOP do play this game in different ways. Both sides tend to appoint industry folks to head the commissions. There is an argument about having someone in that role that knows nothing about the industry and becomes a loose cannon and someone who does know the industry and “right-size” regulation and enforcement.

  16. sherlockj Avatar
    sherlockj

    You want enforcement of nursing home standards. States have sought and been granted federal authority and responsibility to oversee nursing homes. More than half of Virginia’s nursing homes have documented substandard staffing. This column constitutes an open letter to Virginia’s Governor. Advocates for nursing home residents have no one else to petition other than Governor Northam to enforce regulations. Do you have a different view of the proper addressee?

    1. LarrytheG Avatar
      LarrytheG

      No. I’d like to see a fair and balanced narrative here that is not just focusing blame in a political way and partisan manner.

      CMS has always had the ability to “enforce” – correct? Do they take funding away from nursing homes when they do “enforcement”?

      Where are they right now if this is so bad?

      Why are you blaming Northam for something CMS won’t do?

      Do you admit that CMS weakened regulations for infectious disease?

  17. sherlockj Avatar
    sherlockj

    No, CMS does not enforce. That authority and responsibility for oversight of nursing homes is given to the states under the Code of Federal Regulations – 42 CFR 488.301 – that implements federal legislation. The states lobbied for this authority and Congress gave it to them. The regulations are here are very clear and undiluted.
    If CMS weakened regulations for control of infectious disease, I would need to see the reference and investigate. The federal and state pandemic influenza response plans were very clear on the responsibilities of each. That is why the Virginia Department of Health removed the Virginia plan from its website at the beginning of the month. Too damning.
    Again, this is a Virginia blog.

    1. LarrytheG Avatar
      LarrytheG

      Does CMS have the ability to stop Medicare and Medicaid reimbursements?

      Yes, this is a Virginia blog and you have brought the Federal into it because CMS sets the Federal Rules that Virginia is to carry out – much like the EPA and DEQ.

      it’s NOT a Virginia-ONLY issue and you know this.

      CMS regulations weakened – I’ve posted this more than once and you are promoting yourself as an expert – and you’re attacking people, it’s incumbent on you to know the facts:

      https://www.nytimes.com/2020/03/14/business/trump-administration-nursing-homes.html

      I’m not convinced that either you or Gillespi are not connected to RPV at this point. Can you clear that up?

      1. sherlockj Avatar
        sherlockj

        I subscribe to the NY Times and read that article. Good job by the reporters. As they noted, it was a proposed rule that was never implemented.
        I have lost all respect for the Republican Party of Virginia. It is effectively leaderless and has no influence at all on selection of candidates. Similarly the Democratic Party of Virginia (DPV).
        The RPV has no party platform because many it could never get agreement on the planks of any platform. Neither does the DPV.
        The district committees of both parties tend to be dominated by “activists” whose agendas may not match the opinions of the majority of their party members.
        As for the state conventions, I attended one and will never attend another.
        So I am a conservative, but not a member of the Republican Party of Virginia or of the Republican party of Virginia Beach nor will I be in the future. Does that answer your question?

  18. Peter Galuszka Avatar
    Peter Galuszka

    Jim S. As you have written many times, the nation’s health care system is rigged. Setting drug prices is done behind closed doors by Medicare, Big Insurance and Big Pharma. You have noted the COPN situation which is typical of many states. You also have the Virginia AutoDealers Assn. trying to prevent competition from electric Teslas. Virginians and other Americans find it hard to buy the same, but cheaper drugs in Canada. The list goes on. Health care right now is run by oligarchs. It doesn’t work. Why not replace it with a single payer system?I say this coming from a family of doctors including my late father and late uncle, a cousin and a cousin-in-law. Another cousin is, by chance, registrar at Harvard Medical School. She’s not a doctor.

  19. Peter Galuszka Avatar
    Peter Galuszka

    Interesting report but not surprising. It’s been this way for many years. The issue is how to regulate and for private firms, how to comply and get the trained staff they need. Not sure the “magic” if the free market works here.

    1. sherlockj Avatar
      sherlockj

      Peter, I am not asking for market magic. I rather request the state use its authority and responsibility to take actions.
      (1) Temporary management.
      (2) Denial of payment for new admissions.
      (3) Civil money penalties.
      (4) Transfer of residents.
      (5) Closure of the facility and transfer of residents.
      (6) State monitoring.”
      Take Mr. East’s Heritage Hall. Please (old joke). The staffing record of Heritage Hall nursing homes suggests a pattern of non-compliance. Heritage Hall has been doing this long enough that it must be presumed profitable. Transfer enough residents from the homes staffed “much below average” to other long term care facilities or hospitals to ensure that the remaining patients get sufficient staff attention. Take temporary state management control of those facilities. Force a sale in lieu of closure or close the worst of them. I think the market would indeed “work its magic” when it noted that major investments in nursing homes are indeed at risk. The banks who hold debt from these enterprises will do the rest.
      If the state needs to raise Medicaid payments to nursing homes or open state-run nursing homes, do it, but it is not clear without access to tax returns of existing for-profit facilities that money is the issue.
      We have a statewide nursing shortage, so take action to fix that as well. The quickest answer is to recruit RNs in foreign countries. Virginia already participates in an international nurse recruiting program through CGNFS International. Healthcare workers are exempt from Mr. Trump’s move to slow immigration. Governor Northam needs to press this button pretty hard.
      To provide more detail, CGNFS is a one stop shop for international registered nurses. Virginia’s requirements are that RN applicants for initial licensure or professional endorsement either:
      1. Complete the CGFNS Certification Program; or
      2. obtain a Credentials Evaluation Service (CES) Professional Report, both through CGNFS; and
      3. Demonstrate English language proficiency.

      CGFNS VisaScreen® Visa Credentials Assessment Service is a comprehensive screening service for healthcare professionals seeking an occupational visa to work in the United States.
      Applicants who successfully complete CGFNS VisaScreen® receive an official ICHP Certificate for the VisaScreen. This certificate satisfies the United States Federal screening requirements.
      CGFNS International is approved by the United States Department of Homeland Security (DHS) to validate the credentials of nine foreign healthcare professions for occupational visas, of which CGFNS is the only organization to validate seven of those professions.

  20. Policy Student Avatar
    Policy Student

    I caution against hyper-focusing on readily available statistics (like recorded RN contact hours/ patient.) I do not believe people enter nursing homes primarily because they require the care of “RN’s.” Some resident needs can be met by volunteers, aides, doctors, LPNs, food service workers, mental health providers, and others. Do RN stats matter, sure. Should nursing homes should be appropriately staffed? Absolutely! But there is always more to a story than a convenient statistic.

    1. sherlockj Avatar
      sherlockj

      RNs are the full time medical supervisors of nursing homes – the ones with the level of training and experience to make it a “nursing” home.
      Virginia’s Medicaid program will pay for a nursing home only when it is medically necessary. An applicant must show that he or she requires a “nursing home level of care,” meaning that one has a physical or mental condition that requires nursing supervision and assistance with activities of daily living (ADLs). The applicant must show that he or she cannot care for himself or herself.
      Before Medicaid will pay for nursing home care, a “pre-admission screening” is required. These screenings are usually done by a nurse or social worker who visits the applicant wherever he or she is living when applying for help. The screener uses a form, called the Virginia Uniform Assessment Instrument, to help evaluate whether the applicant needs help with certain activities, including bathing, eating, taking medication, using the bathroom, moving around, and dressing. The screener will decide how much assistance is needed to get those activities done. Whether the applicant meets the nursing home level of care depends on the combination of the number of things with which help is needed and the level of help needed.
      Medicaid uses the information in the screening to decide whether a nursing home is needed and, if so, what kind of nursing home is appropriate. In general, for a nursing home to be considered medically necessary, the patient must have a medical condition that is so serious that he or she needs the level of nursing care that is only available in an institution.
      You will notice from my posts that Medicare reports RN staffing separately. The reason for that is that it is considered crucial. That is why it is a “readily available statistic”. If not the currently posted statistics, what data would you like to collect?

  21. LarrytheG Avatar
    LarrytheG

    Yep. In terms of political money – go to VPAP to see who gets money from Virginia Healthcare Association. You’ll see that they do like a lot of such organizations – both sides of the aisle get it.

    Next – On the right, including the Trump administration right now, they typically work to get rid of regulations on the premise that they drive up costs.

    So you have this situation where the argument is that regulation drives up costs – but at the same time the nursing homes are condemned for inadequate staffing that directly relates to the cost of having adequate staffing.

    Then, one more step, when ratings for staffing levels go down, then use it to go after political opponents which is what we see here with Mr. SGillispie routing them on.

    One would think that, no, you can’t have it both ways – i.e. lobby to remove regulations that add costs then at the same time go after the same nursing homes for cost-cutting staff reductions – and then go after the Governor demanding “investigations” and sanctions.

    This is how partisan politics works these days.

    Across the country – from New York to Washington State to Texas and Florida, nursing homes are all pretty much having the same issues in large part because nursing homes, as currently operated and regulated are not designed to operate with regard to dealing with the corona virus.

    So, rather than playing a political blame game like we see here, what would be advocated for reforms?

    Do we hear from the critics here in terms of what should be done to increase staffing? Nope. Because that would increase costs.

    What exactly is wanted? Oh.. we want cheaper nursing homes with more staffing, right?

    Want to increase regulation dictating more staffing? Is that a recommendation? Nope.

    so what is this? what is this really about?

    It’s not about calls to increase staffing…. It’s not about the State requiring staffing inreases or moving patients to less crowded nursing homes or any of that.. nope.

    nope.. it’s about assigning blame and coming from conservatives/GOP and aimed at a Democratic Gov.

  22. sherlockj Avatar
    sherlockj

    Your contention that saving sick and inform old people from the documented lack of nurses to care for them is somehow political does you no credit. I would hope that everyone would get behind this cause.
    We don’t need to increase regulation. More than half of Virginia’s nursing homes have documented substandard staffing under current regulation. It is enforcement we seek.
    As for solutions, see my note to Peter above regarding recruiting foreign nurses.

    1. LarrytheG Avatar
      LarrytheG

      Another political ploy – ” oh the poor victims”. 99% of this is about assigning blame , NOT helping those victims.

      Regulation that required increased staffing was gutted by Trump and now the claim is we need better “enforcement”. That dog don’t hunt. It’s totally disingenuous. “enforcement” of what? regulations that have been loosened? Are you going to hire at taxpayer expense more folks to do that and more staff to take actions against nursing homes?

      when you take away the regulation, what exactly are you going to “enforce”?

      re: recruiting foreign nurses? REALLY? Doesn’t that run counter to the idea of jobs for Americans and pay them a fair living wage? We’re gonna to use more immigration for cheap labor?

      When I see a fair and balanced narrative here, I’ll get off your case. Until then, I’m going to point out when it is political and partisan.

      BOTH sides – Dems and GOP do play this game in different ways. Both sides tend to appoint industry folks to head the commissions. There is an argument about having someone in that role that knows nothing about the industry and becomes a loose cannon and someone who does know the industry and “right-size” regulation and enforcement.

      1. sherlockj Avatar
        sherlockj

        Simple question. Do you support enforcement of current nursing home staffing standards? One word answer will do.

        1. LarrytheG Avatar
          LarrytheG

          I DO – but I abhor the politics on display on this.

          Let’s have a fair and honest discussion about it without going after political folks you don’t agree with.

          how about it?

        2. Steve Haner Avatar
          Steve Haner

          One finds oneself all the way back in Government 101 hearing that lecture about the “iron triangle” that so dominates government decisions making. I haven’t looked, but the statute may require a board member who is from the industry, intended to be a rep and even advocate for the industry. This is in part about lobbying and campaign money, but those are dwarfed by the ways Medicare and Medicaid create perverse incentives. Again, still deep in that libertarian-informed book, but the real problem is the third-party payer model and that “iron triangle.”

          1. LarrytheG Avatar
            LarrytheG

            Jim Sherlock – I want you to notice what Steve is saying here. He’s talking about the system and how it works – not left/right politics at least in the specifics here although I’m sure he has a view.

            But the problem of nursing homes ought not be a game of political “gotcha” if we’re serious about reforms and fixes.

            It’s way more than an “enforcement” issue.

            If you think that there where is CMS “enforcement”?

          2. sherlockj Avatar
            sherlockj

            The statute indeed does require a board member from the industry, but it doesn’t need to be one of the worst violators of nursing home staffing norms.
            You and I agree entirely on the iron triangle. It exists in every state, but it is hard to imagine another state so unabashedly and publicly corrupt. That is because the general population doesn’t know enough about it and its effects on them to care. I have not succeeded in solving that, but I will continue to try.
            As for the regional press, or what little is left of it, they have so more sacred cows than New Dehli. Regional powerhouses tend to be protected. There are a few honorable exceptions – the Roanoke Times comes to mind – but not enough.

          3. Dick Hall-Sizemore Avatar
            Dick Hall-Sizemore

            Can’t imagine a state more corrupt? Try Louisiana.

  23. sherlockj Avatar
    sherlockj

    You want enforcement of nursing home standards. States have sought and been granted federal authority and responsibility to oversee nursing homes. More than half of Virginia’s nursing homes have documented substandard staffing. This column constitutes an open letter to Virginia’s Governor. Advocates for nursing home residents have no one else to petition other than Governor Northam to enforce regulations. Do you have a different view of the proper addressee?

    1. LarrytheG Avatar
      LarrytheG

      No. I’d like to see a fair and balanced narrative here that is not just focusing blame in a political way and partisan manner.

      CMS has always had the ability to “enforce” – correct? Do they take funding away from nursing homes when they do “enforcement”?

      Where are they right now if this is so bad?

      Why are you blaming Northam for something CMS won’t do?

      Do you admit that CMS weakened regulations for infectious disease?

  24. sherlockj Avatar
    sherlockj

    No, CMS does not enforce. That authority and responsibility for oversight of nursing homes is given to the states under the Code of Federal Regulations – 42 CFR 488.301 – that implements federal legislation. The states lobbied for this authority and Congress gave it to them. The regulations are here are very clear and undiluted.
    If CMS weakened regulations for control of infectious disease, I would need to see the reference and investigate. The federal and state pandemic influenza response plans were very clear on the responsibilities of each. That is why the Virginia Department of Health removed the Virginia plan from its website at the beginning of the month. Too damning.
    Again, this is a Virginia blog.

    1. LarrytheG Avatar
      LarrytheG

      Does CMS have the ability to stop Medicare and Medicaid reimbursements?

      Yes, this is a Virginia blog and you have brought the Federal into it because CMS sets the Federal Rules that Virginia is to carry out – much like the EPA and DEQ.

      it’s NOT a Virginia-ONLY issue and you know this.

      CMS regulations weakened – I’ve posted this more than once and you are promoting yourself as an expert – and you’re attacking people, it’s incumbent on you to know the facts:

      https://www.nytimes.com/2020/03/14/business/trump-administration-nursing-homes.html

      I’m not convinced that either you or Gillespi are not connected to RPV at this point. Can you clear that up?

      1. sherlockj Avatar
        sherlockj

        I subscribe to the NY Times and read that article. Good job by the reporters. As they noted, it was a proposed rule that was never implemented.
        I have lost all respect for the Republican Party of Virginia. It is effectively leaderless and has no influence at all on selection of candidates. Similarly the Democratic Party of Virginia (DPV).
        The RPV has no party platform because many it could never get agreement on the planks of any platform. Neither does the DPV.
        The district committees of both parties tend to be dominated by “activists” whose agendas may not match the opinions of the majority of their party members.
        As for the state conventions, I attended one and will never attend another.
        So I am a conservative, but not a member of the Republican Party of Virginia or of the Republican party of Virginia Beach nor will I be in the future. Does that answer your question?

  25. sherlockj Avatar
    sherlockj

    You did see in a previous column that I filed a formal complaint with CMS requesting they investigate Virginia’s conduct of its oversight of nursing homes under federal regulations and with the Justice Department to investigate possible state violation of Title II of the Americans with Disabilities Act. Those are federal roles.

    1. LarrytheG Avatar
      LarrytheG

      Yes, and how ironic, you’re going to the FEDS to ENFORCE regulations that you accuse Virginia of not enforcing.

      Does that mean the Feds issues regulations and enforce them also?

      Can you back off the politics here and admit the reality that this issue is not about gotcha politics ?

      How about a non-political discussion of the nursing home issue?

  26. sherlockj Avatar
    sherlockj

    You did see in a previous column that I filed a formal complaint with CMS requesting they investigate Virginia’s conduct of its oversight of nursing homes under federal regulations and with the Justice Department to investigate possible state violation of Title II of the Americans with Disabilities Act. Those are federal roles.

    1. LarrytheG Avatar
      LarrytheG

      Yes, and how ironic, you’re going to the FEDS to ENFORCE regulations that you accuse Virginia of not enforcing.

      Does that mean the Feds issues regulations and enforce them also?

      Can you back off the politics here and admit the reality that this issue is not about gotcha politics ?

      How about a non-political discussion of the nursing home issue?

  27. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    “Reed Fawell 3rd | April 23, 2020 at 6:03 pm | Reply

    The silence is deafening. As it should be.”

    The case now is closed with one exception, this:

    “CrazyJD | April 23, 2020 at 6:30 pm | Reply

    Most of you know that I don’t like much of what government does, and generally they do it very badly. There are a couple of exceptions, namely, those things that, structurally, the private sector cannot do: Police, fire, environmental protection (the latter by a rational entity not driven by agenda) But additionally, I think it may be a legitimate function of government see to the protection of those citizens who are truly unable to protect themselves. This would include the mentally ill and those in nursing homes. We can argue about who foots the bill, but generally speaking it is a legitimate governmental function to regulate nursing homes to the extent necessary for the protection of residents. To me, it’s clear that this is not being done in Virginia.”

    NOTE HOW, INCREASINGLY here on BR, the debate, the longer it gets, devolves ever more downward into confused darkness, rather than upwards into light and clear understanding.

    Even the simplest and most obvious of newly uncovered important issues never fail to get obscured and mucked up by our endless mindless dialogue, falling into dark holes.

    This is a grand metaphor of our time, this endless verbal game-playing, without any positive result.

  28. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    “Reed Fawell 3rd | April 23, 2020 at 6:03 pm | Reply

    The silence is deafening. As it should be.”

    The case now is closed with one exception, this:

    “CrazyJD | April 23, 2020 at 6:30 pm | Reply

    Most of you know that I don’t like much of what government does, and generally they do it very badly. There are a couple of exceptions, namely, those things that, structurally, the private sector cannot do: Police, fire, environmental protection (the latter by a rational entity not driven by agenda) But additionally, I think it may be a legitimate function of government see to the protection of those citizens who are truly unable to protect themselves. This would include the mentally ill and those in nursing homes. We can argue about who foots the bill, but generally speaking it is a legitimate governmental function to regulate nursing homes to the extent necessary for the protection of residents. To me, it’s clear that this is not being done in Virginia.”

    NOTE HOW, INCREASINGLY here on BR, the debate, the longer it gets, devolves ever more downward into confused darkness, rather than upwards into light and clear understanding.

    Even the simplest and most obvious of newly uncovered important issues never fail to get obscured and mucked up by our endless mindless dialogue, falling into dark holes.

    This is a grand metaphor of our time, this endless verbal game-playing, without any positive result.

  29. Peter Galuszka Avatar
    Peter Galuszka

    Jim S. As you have written many times, the nation’s health care system is rigged. Setting drug prices is done behind closed doors by Medicare, Big Insurance and Big Pharma. You have noted the COPN situation which is typical of many states. You also have the Virginia AutoDealers Assn. trying to prevent competition from electric Teslas. Virginians and other Americans find it hard to buy the same, but cheaper drugs in Canada. The list goes on. Health care right now is run by oligarchs. It doesn’t work. Why not replace it with a single payer system?I say this coming from a family of doctors including my late father and late uncle, a cousin and a cousin-in-law. Another cousin is, by chance, registrar at Harvard Medical School. She’s not a doctor.

  30. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    Jim, thank you for your advocacy on this issue. In order for their existence to have any purpose, regulations need to be enforced. It is thorny issue, which is not often examined. I do have a couple of questions:
    1. Do you know how many, if any, Virginia nursing homes have had their licenses revoked in the last XX years? I could not readily find anything on the VDH website about compliance actions.
    2. The staffing levels at the Heritage Hall facilities may be below national averages, but do they meet state standards?

    By the way, nursing home regulation is not the only area in which enforcement is an issue. Even closing an assisted living center after it has been found in violation is often a problem. https://www.virginiamercury.com/2018/10/01/despite-deaths-dozens-of-violations-and-revoked-licenses-richmond-assisted-living-facility-remains-open/

    1. sherlockj Avatar
      sherlockj

      The answers to your questions
      1. Nor can I.
      2. Code of Virginia Title 32.1. Health Chapter 5. Regulation of Medical Care Facilities and Services » Article 1. Hospital and Nursing Home Licensure and Inspection » § 32.1-127. Regulations is where the state law sits. You will note that it directs the Board (of Health) to promulgate regulations to carry out the provisions of that article. Mr. East, of course, is the nursing home industry member of the Board.
      That brings us to Administrative Code, Title 12. Health » Agency 5. Department of Health » Chapter 371. Regulations for the Licensure of Nursing Facilities. When you read these you will understand that in the case of inspections, the VDH Office of Long Term Care inspectors are given leeway in determining the severity and thus the enforcement actions in the case of discrepancies. But the staffing issues are subject to quarterly reporting by nursing homes to the states that must be based on actual payroll records. You will read below that VDH has ample authority to take action against facilities that report one star (much below average) staffing, especially RN staffing. Yet 42 of Virginia’s nursing homes reported “much below average” staffing as of March 30, and there is no indication that VDH is taking now or has in the past taken any enforcement action against them. If a nursing home is proven to abuse an individual patient, action may follow. In the case of gross understaffing, which abuses all patients, there is no record that I can find of enforcement.
      Some provisions of the Code of Virginia and Administrative Code of Virginia in direct answer to your question:
      12VAC5-371-60. on-Site Inspections
      A. The licensing representative shall make unannounced on-site inspections of the nursing facility. The licensee shall be responsible for correcting any deficiencies found during any on-site inspection. Compliance with all standards will be determined by the (VDH) Office of Long term Care.
      G. The administrator of record (individual nursing home administrator) shall be responsible for assuring the plan of correction is implemented and monitored so that compliance is maintained.
      12VAC5-371-90. Administrative Sanctions.
      D. Violations which in the judgment of the OLC jeopardize the health and safety of residents shall be sufficient cause for immediate imposition of this section.
      12VAC5-371-180. Infection Control.
      A. The nursing facility shall establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection.
      12VAC5-371-210. Nurse Staffing.
      A. A nursing supervisor, designated by the director of nursing, shall be responsible for all nursing activities in the facility, or in the section to which assigned, including:
      1. Making daily visits to determine resident physical, mental, and emotional status and implementing any required nursing intervention;
      2. Reviewing medication records for completeness, accuracy in the transcription of physician orders, and adherence to stop-order policies;
      3. Reviewing resident plans of care for appropriate goals and approaches, and making revisions based on individual needs;
      4. Assigning to the nursing staff responsibility for nursing care;
      5. Supervising and evaluating performance of all nursing personnel on the unit; and
      6. Keeping the director of nursing services, or director of nursing designee, informed of the status of residents and other related matters.
      B. The nursing facility shall provide qualified nurses and certified nurse aides on all shifts, seven days per week, in sufficient number to meet the assessed nursing care needs of all residents.
      C. Nursing personnel, including registered nurses, licensed practical nurses, and certified nurse aides shall be assigned duties consistent with their education, training and experience.
      D. Weekly time schedules shall be maintained and shall indicate the number and classification of nursing personnel who worked on each unit for each shift. Schedules shall be retained for one year.

      1. LarrytheG Avatar
        LarrytheG

        These Va Codes are Virginians implementation of CMS regs. When the CMS regs change, the Va Code is updated to stay consistent.

        in terms of CMS rollback of nursing home regulations:

        Nursing Home Deregulation Continues, Despite Substantial Risk to Residents

        September 2019

        Background

        Under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) has been advancing efforts to deregulate the nursing home industry by rolling back the rights and protections of nursing home residents. These efforts include reducing accountability for substandard care, such as by shifting the default financial penalty for the most serious health violations from a daily fine for every day of noncompliance to just a single fine, no matter how long the violation persists. Unfortunately, CMS has now followed up such damaging efforts by issuing a proposed rule rolling back the nursing home Requirements of Participation, proposing to reduce survey frequency for so-called “top-performing” facilities, and reversing the ban on pre-dispute arbitration agreements. This alert provides information on some of the key areas of concern for residents and families.

        https://www.medicareadvocacy.org/nursing-home-deregulation-continues-despite-substantial-risk-to-residents/

        This is how the game is played. When the GOP takes control , they roll back regulations… when the Dems get in – they re-institute them.

        The same thing is going on with the EPA and OSHA – regulations being rolled back.

        When that happens, the states re-jigger their enforcement actions based on the rollbacks.

        CMS still retains the authority to take Medicare/Medicaid reimbursements away from nursing homes that actually do FAIL, until then the regulators try to nudget the homes back to better compliance.

        If VDH was malfeasance in their work – we’d see it across the state – in lax enforcement at 280 nursing homes.

        That is not the case. Instead, there are some homes across the state that are not meeting the required metrics – that ARE REPORTED to CMS as well as VDH.

        What’s actually worth discussing in not who shot John politics… but rather the issue of private sector nursing homes and how they should be regulated.

        Conservatives tend to want to regulate in a different way than Dems.

        Dems like proscripted regs. Conservatives tend to want to specify metrics and outcomes and let the company decide how to meet them.

        I actually favor the latter method if the nursing home itself is going to remain private sector, non-government but the whole thing about nursing homes is really at the core of what things the govt should do and what things the private sector should do – and …regulation.

        I’m not saying that we should require accountability but I am saying when it comes to nursing homes – things are so bad that shutting one down – and moving the residents – may well not be the best thing for the residents – especially if they get moved to another facility, overload that facility and cause it to fail.

        You also have to ask yourself WHY the “free market” does not meet this need to being with and why Govt is required – which many conservatives will say – guarantees failure.

        I just think the “who shot John” politics of nursing homes is just bogus partisan foolishness. Northam/VDH is no worse and no better than many other states, none of which don’t have problem nursing homes also.

  31. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    Jim, thank you for your advocacy on this issue. In order for their existence to have any purpose, regulations need to be enforced. It is thorny issue, which is not often examined. I do have a couple of questions:
    1. Do you know how many, if any, Virginia nursing homes have had their licenses revoked in the last XX years? I could not readily find anything on the VDH website about compliance actions.
    2. The staffing levels at the Heritage Hall facilities may be below national averages, but do they meet state standards?

    By the way, nursing home regulation is not the only area in which enforcement is an issue. Even closing an assisted living center after it has been found in violation is often a problem. https://www.virginiamercury.com/2018/10/01/despite-deaths-dozens-of-violations-and-revoked-licenses-richmond-assisted-living-facility-remains-open/

    1. sherlockj Avatar
      sherlockj

      The answers to your questions
      1. Nor can I.
      2. Code of Virginia Title 32.1. Health Chapter 5. Regulation of Medical Care Facilities and Services » Article 1. Hospital and Nursing Home Licensure and Inspection » § 32.1-127. Regulations is where the state law sits. You will note that it directs the Board (of Health) to promulgate regulations to carry out the provisions of that article. Mr. East, of course, is the nursing home industry member of the Board.
      That brings us to Administrative Code, Title 12. Health » Agency 5. Department of Health » Chapter 371. Regulations for the Licensure of Nursing Facilities. When you read these you will understand that in the case of inspections, the VDH Office of Long Term Care inspectors are given leeway in determining the severity and thus the enforcement actions in the case of discrepancies. But the staffing issues are subject to quarterly reporting by nursing homes to the states that must be based on actual payroll records. You will read below that VDH has ample authority to take action against facilities that report one star (much below average) staffing, especially RN staffing. Yet 42 of Virginia’s nursing homes reported “much below average” staffing as of March 30, and there is no indication that VDH is taking now or has in the past taken any enforcement action against them. If a nursing home is proven to abuse an individual patient, action may follow. In the case of gross understaffing, which abuses all patients, there is no record that I can find of enforcement.
      Some provisions of the Code of Virginia and Administrative Code of Virginia in direct answer to your question:
      12VAC5-371-60. on-Site Inspections
      A. The licensing representative shall make unannounced on-site inspections of the nursing facility. The licensee shall be responsible for correcting any deficiencies found during any on-site inspection. Compliance with all standards will be determined by the (VDH) Office of Long term Care.
      G. The administrator of record (individual nursing home administrator) shall be responsible for assuring the plan of correction is implemented and monitored so that compliance is maintained.
      12VAC5-371-90. Administrative Sanctions.
      D. Violations which in the judgment of the OLC jeopardize the health and safety of residents shall be sufficient cause for immediate imposition of this section.
      12VAC5-371-180. Infection Control.
      A. The nursing facility shall establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection.
      12VAC5-371-210. Nurse Staffing.
      A. A nursing supervisor, designated by the director of nursing, shall be responsible for all nursing activities in the facility, or in the section to which assigned, including:
      1. Making daily visits to determine resident physical, mental, and emotional status and implementing any required nursing intervention;
      2. Reviewing medication records for completeness, accuracy in the transcription of physician orders, and adherence to stop-order policies;
      3. Reviewing resident plans of care for appropriate goals and approaches, and making revisions based on individual needs;
      4. Assigning to the nursing staff responsibility for nursing care;
      5. Supervising and evaluating performance of all nursing personnel on the unit; and
      6. Keeping the director of nursing services, or director of nursing designee, informed of the status of residents and other related matters.
      B. The nursing facility shall provide qualified nurses and certified nurse aides on all shifts, seven days per week, in sufficient number to meet the assessed nursing care needs of all residents.
      C. Nursing personnel, including registered nurses, licensed practical nurses, and certified nurse aides shall be assigned duties consistent with their education, training and experience.
      D. Weekly time schedules shall be maintained and shall indicate the number and classification of nursing personnel who worked on each unit for each shift. Schedules shall be retained for one year.

      1. LarrytheG Avatar
        LarrytheG

        These Va Codes are Virginians implementation of CMS regs. When the CMS regs change, the Va Code is updated to stay consistent.

        in terms of CMS rollback of nursing home regulations:

        Nursing Home Deregulation Continues, Despite Substantial Risk to Residents

        September 2019

        Background

        Under the Trump Administration, the Centers for Medicare & Medicaid Services (CMS) has been advancing efforts to deregulate the nursing home industry by rolling back the rights and protections of nursing home residents. These efforts include reducing accountability for substandard care, such as by shifting the default financial penalty for the most serious health violations from a daily fine for every day of noncompliance to just a single fine, no matter how long the violation persists. Unfortunately, CMS has now followed up such damaging efforts by issuing a proposed rule rolling back the nursing home Requirements of Participation, proposing to reduce survey frequency for so-called “top-performing” facilities, and reversing the ban on pre-dispute arbitration agreements. This alert provides information on some of the key areas of concern for residents and families.

        https://www.medicareadvocacy.org/nursing-home-deregulation-continues-despite-substantial-risk-to-residents/

        This is how the game is played. When the GOP takes control , they roll back regulations… when the Dems get in – they re-institute them.

        The same thing is going on with the EPA and OSHA – regulations being rolled back.

        When that happens, the states re-jigger their enforcement actions based on the rollbacks.

        CMS still retains the authority to take Medicare/Medicaid reimbursements away from nursing homes that actually do FAIL, until then the regulators try to nudget the homes back to better compliance.

        If VDH was malfeasance in their work – we’d see it across the state – in lax enforcement at 280 nursing homes.

        That is not the case. Instead, there are some homes across the state that are not meeting the required metrics – that ARE REPORTED to CMS as well as VDH.

        What’s actually worth discussing in not who shot John politics… but rather the issue of private sector nursing homes and how they should be regulated.

        Conservatives tend to want to regulate in a different way than Dems.

        Dems like proscripted regs. Conservatives tend to want to specify metrics and outcomes and let the company decide how to meet them.

        I actually favor the latter method if the nursing home itself is going to remain private sector, non-government but the whole thing about nursing homes is really at the core of what things the govt should do and what things the private sector should do – and …regulation.

        I’m not saying that we should require accountability but I am saying when it comes to nursing homes – things are so bad that shutting one down – and moving the residents – may well not be the best thing for the residents – especially if they get moved to another facility, overload that facility and cause it to fail.

        You also have to ask yourself WHY the “free market” does not meet this need to being with and why Govt is required – which many conservatives will say – guarantees failure.

        I just think the “who shot John” politics of nursing homes is just bogus partisan foolishness. Northam/VDH is no worse and no better than many other states, none of which don’t have problem nursing homes also.

  32. Policy Student Avatar
    Policy Student

    I caution against hyper-focusing on readily available statistics (like recorded RN contact hours/ patient.) I do not believe people enter nursing homes primarily because they require the care of “RN’s.” Some resident needs can be met by volunteers, aides, doctors, LPNs, food service workers, mental health providers, and others. Do RN stats matter, sure. Should nursing homes should be appropriately staffed? Absolutely! But there is always more to a story than a convenient statistic.

    1. sherlockj Avatar
      sherlockj

      RNs are the full time medical supervisors of nursing homes – the ones with the level of training and experience to make it a “nursing” home.
      Virginia’s Medicaid program will pay for a nursing home only when it is medically necessary. An applicant must show that he or she requires a “nursing home level of care,” meaning that one has a physical or mental condition that requires nursing supervision and assistance with activities of daily living (ADLs). The applicant must show that he or she cannot care for himself or herself.
      Before Medicaid will pay for nursing home care, a “pre-admission screening” is required. These screenings are usually done by a nurse or social worker who visits the applicant wherever he or she is living when applying for help. The screener uses a form, called the Virginia Uniform Assessment Instrument, to help evaluate whether the applicant needs help with certain activities, including bathing, eating, taking medication, using the bathroom, moving around, and dressing. The screener will decide how much assistance is needed to get those activities done. Whether the applicant meets the nursing home level of care depends on the combination of the number of things with which help is needed and the level of help needed.
      Medicaid uses the information in the screening to decide whether a nursing home is needed and, if so, what kind of nursing home is appropriate. In general, for a nursing home to be considered medically necessary, the patient must have a medical condition that is so serious that he or she needs the level of nursing care that is only available in an institution.
      You will notice from my posts that Medicare reports RN staffing separately. The reason for that is that it is considered crucial. That is why it is a “readily available statistic”. If not the currently posted statistics, what data would you like to collect?

  33. Policy Student Avatar
    Policy Student

    Thank you for your reply. I am somewhat familiar with Medicare and the screening process, having served as a patient advocate. I will retract my argument if you or someone else can connect the “so what?” dots for me. After controlling for other factors like patient condition, SES, other staff, etc., what is the impact of RN contact hours on preventable resident deaths, falls, and hospitalizations?

    I am not qualified to suggest the best measurements of nursing home care. A quick scan of literature suggests external mortality causes include falls, nutrition issues, choking and the use of restraint. Perhaps these are also useful things to measure but I defer to nursing/ public health scholars there.

    I appreciate that no-one has endless resources to capture and analyze data. In my research utopia, we could efficiently conduct robust quantitative and qualitative analyses of Grandma’s nursing home for free.

  34. Policy Student Avatar
    Policy Student

    Thank you for your reply. I am somewhat familiar with Medicare and the screening process, having served as a patient advocate. I will retract my argument if you or someone else can connect the “so what?” dots for me. After controlling for other factors like patient condition, SES, other staff, etc., what is the impact of RN contact hours on preventable resident deaths, falls, and hospitalizations?

    I am not qualified to suggest the best measurements of nursing home care. A quick scan of literature suggests external mortality causes include falls, nutrition issues, choking and the use of restraint. Perhaps these are also useful things to measure but I defer to nursing/ public health scholars there.

    I appreciate that no-one has endless resources to capture and analyze data. In my research utopia, we could efficiently conduct robust quantitative and qualitative analyses of Grandma’s nursing home for free.

  35. A self-inflicted nursing home crisis in Virginia – Part 1 | Bacon's Rebellion

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