Availability of Clinical Workforce for Nursing Homes, 2020 (Virginia Department of Health)
Summary
This is the Virginia Department of Health (VDH) report to the General Assembly, Availability of Clinical Workforce for Nursing Homes, 2020, submitted in response to Chapter 932 of the 2020 Acts of Assembly. The Executive Summary states that the clinical workforce in Virginia, particularly certified nurse aides (CNAs) and licensed practical nurses (LPNs), has declined in recent years. It says a work group that met eight times between July and November 2020 made recommendations on education, wages and expansion of the existing workforce, such as service learning credit and increased CNA wages tied to regional living wage standards. An appendix from Dignity for the Aged reports a survey of 100 CNAs in which Low Wages was cited at 59%.
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“Availability of Clinical Workforce for Nursing Homes, 2020 (Virginia Department of Health).”
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AVA I L A B I L I T Y O F
C L I N I C A L WO R K F O R C E
FOR NURSING HOMES
REPORT TO THE GENERAL ASSE MBLY
2020
VI RGI NI A DEPART MENT OF HEALT H
OFFICE OF LICENSURE AND CERTIFICATION
GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
P R E FA C E
The Virginia Department of Health (VDH) is submitting this report in response to the legislative mandate
in Chapter 932 of the 2020 Acts of Assembly, which directed VDH to convene a work group to study and
make recommendations on the availability of the clinical workforce in nursing homes. The legislative mandate
requires VDH to submit its report “to the Chairmen of the Senate Committee on Education and Health and
the House Committee on Health, Welfare and Institutions on or before November 15, 2020.”
MEMBERS OF THE WORK GROUP
Heather K. Anderson, MPH – Director, Division of Primary Care and Rural Health, Office of Health Equity,
Virginia Department of Health
Todd Barnes – Administrator, Virginia Veterans Care Center, Virginia Department of Veteran Services
Alaysia Black Hackett, Exec. JD, MPA – Special Assistant to the Chief Diversity Officer, Office of
Diversity, Equity, and Inclusion, Office of the Governor
Karen Brimm, MA – Community Services Manager, Virginia Department for the Deaf and Hard of Hearing
Jewell Bronaugh – Commissioner, Virginia Department of Agriculture and Consumer Services
Elizabeth A. Carter, PhD – Director, Healthcare Workforce Data Center, Virginia Department of Health
Professions
Alicia Cundiff – Government Affairs Specialist, SpottsFain Consulting
Lionel DeCuir – Deputy Director, Dignity for the Aged
Kurt Elward, MD, MPH – Senior Advisor, Virginia Department of Medical Assistance Services
Meaghan Green – Special Assistant to the Chief Workforce Advisor, Office of Governor Ralph Northam
Erin Hines – Facility Activity Coordinator, Dignity for the Aged
Susan Hines – Facility Activity Coordinator, Dignity for the Aged
Christina Holloway – Owner, Beach Health and Wellness
Judy Jackson – Virginia Department for the Blind and Vision Impaired
W. Scott Johnson, Esq. – Hancock, Daniel & Johnson, P.C.
The Honorable Jennifer A. Kiggans – Senator, Senate of Virginia
Bob Kukich – Treasurer, Dignity for the Aged
Sam Kukich – Director, Dignity for the Aged
Joani Latimer – State Long-Term Care Ombudsman, Virginia Department for Aging and Rehabilitative
Services
Heather Legere, MSW, LNHA – Assistant Administrator, Virginia Veterans Care Center, Department of
Veterans Services
Vivienne Pierce McDaniel, DNP, MSN, RN – Diversity, Equity, and Inclusion Chair, Virginia Nurses
Association
Dana Parsons – Vice President and Legislative Counsel, LeadingAge Virginia
Kathryn Paxton – Policy Analyst, Office of Policy, Planning, and Research, Department of Agriculture and
Consumer Services
April Payne – Vice President of Quality Improvement, Virginia Health Care Association | Virginia Center for
Assisted Living
Eric Raff – Director, Virginia Department for the Deaf and Hard of Hearing
Charlette Ridout, RN, MS, CNE – Deputy Executive Director, Board of Nursing, Virginia Department of
Health Professions
Barbara Seymour, BSW, HCCS – Division of Aging and Disability Services, Virginia Department of Medical
Assistance Services
Randall Stamper – Assistant Vice Chancellor, Virginia Community College System
Corie Tillman Wolf, JD – Executive Director, Board of Long-Term Care Administrators, Virginia
Department of Health Professions
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
STAFF TO THE TASK FORCE
Rebekah E. Allen, JD – Senior Policy Analyst, Office of Licensure and Certification, Virginia Department of
Health
A. Carole Pratt, DDS – Senior Advisor and Confidential Assistant for Policy, Governmental and Regulatory
Affairs, Virginia Department of Health
Brenden Rivenbark – Senior Policy Analyst, Governmental and Regulatory Affairs, Virginia Department of
Health
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
TA B L E O F C ON T E N T S
Preface..................................................................................................................................................... i
Members of the Work Group .................................................................................................................................... i
Staff to the Task Force ............................................................................................................................................... ii
Table of Contents.................................................................................................................................. iii
Executive Summary ............................................................................................................................... v
Introduction ........................................................................................................................................... 1
Study Mandate ............................................................................................................................................................. 1
Work Group Activities ............................................................................................................................................... 1
July 6 Meeting .......................................................................................................................................................... 1
July 20 Meeting ........................................................................................................................................................ 1
August 4 Meeting..................................................................................................................................................... 2
August 17 Meeting .................................................................................................................................................. 2
August 31 Meeting .................................................................................................................................................. 2
September 25 Meeting .............................................................................................................................................. 2
September 30 Meeting .............................................................................................................................................. 2
November 9 Meeting ................................................................................................................................................ 2
Report Outline ............................................................................................................................................................. 2
Virginia’s Clinical Workforce for Nursing Homes ................................................................................ 4
State of the Workforce ............................................................................................................................................... 4
CMS Five-Star Ratings for Workforce ..................................................................................................................... 6
Policy Recommendations ...................................................................................................................... 8
Education-Related Recommendations..................................................................................................................... 8
Service Learning and Volunteerism........................................................................................................................... 8
Student Outreach .................................................................................................................................................... 10
Educational Funding .............................................................................................................................................. 11
Wage-Related Recommendations ........................................................................................................................... 12
Financial Relief Programs....................................................................................................................................... 12
Minimum Wage ..................................................................................................................................................... 12
Medicaid Reimbursement ........................................................................................................................................ 14
Workforce-Related Recommendations .................................................................................................................. 16
Supporting Persons with Disabilities ....................................................................................................................... 16
Supporting Veterans ............................................................................................................................................... 17
Other Recommendations.......................................................................................................................................... 18
Appendix A – Chapter 932 of the 2020 Acts of Assembly .................................................................... 20
Appendix B – Acronyms and Abbreviations.........................................................................................21
Appendix C – Work Group Meeting Minutes ..................................................................................... 23
July 6, 1:00 P.M. ......................................................................................................................................................... 23
July 20, 1:00 PM ......................................................................................................................................................... 24
August 4, 1:00 P.M. ................................................................................................................................................... 25
August 17, 1:00 P.M. ................................................................................................................................................. 26
August 31, 1:00 P.M. ................................................................................................................................................. 28
September 25, 1:00 P.M. .......................................................................................................................................... 29
September 30, 1:00 P.M. .......................................................................................................................................... 30
November 9, 9:00 A.M. ............................................................................................................................................ 31
Appendix D – Summary of Written Comments from the Public ......................................................... 33
July 6 Meeting ............................................................................................................................................................ 33
July 20 Meeting .......................................................................................................................................................... 33
August 4 Meeting....................................................................................................................................................... 33
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
August 17 Meeting .................................................................................................................................................... 34
August 31 Meeting .................................................................................................................................................... 35
September 25 Meeting .............................................................................................................................................. 35
September 30 Meeting .............................................................................................................................................. 35
November 9 Meeting ................................................................................................................................................ 35
Appendix E – Stakeholder Voting Record on Work Group Recommendations ................................. 36
Appendix F – Stakeholder Explanations of Opposition to Specific Recommendations .................... 42
Recommendation #1 ................................................................................................................................................ 42
Recommendation #2 ................................................................................................................................................ 42
Recommendation #3 ................................................................................................................................................ 42
Recommendation #4 ................................................................................................................................................ 42
Recommendation #5 ................................................................................................................................................ 42
Recommendation #6 ................................................................................................................................................ 42
Recommendation #7 ................................................................................................................................................ 43
Recommendation #8 ................................................................................................................................................ 43
Recommendation #9 ................................................................................................................................................ 43
Recommendation #10 .............................................................................................................................................. 43
Recommendation #11 .............................................................................................................................................. 43
Recommendation #12 .............................................................................................................................................. 43
Recommendation #21 .............................................................................................................................................. 43
Recommendation #22 .............................................................................................................................................. 44
Recommendation #23 .............................................................................................................................................. 44
Recommendation #25 .............................................................................................................................................. 44
Recommendation #26 .............................................................................................................................................. 44
Recommendation #27 .............................................................................................................................................. 45
Recommendation #28 .............................................................................................................................................. 45
Recommendation #30 .............................................................................................................................................. 45
Recommendation #31 .............................................................................................................................................. 45
Recommendation #32 .............................................................................................................................................. 45
Recommendation #33 .............................................................................................................................................. 45
Recommendation #34 .............................................................................................................................................. 45
Appendix G – Stakeholder Comments on Work Group Draft Report ................................................. 47
Dignity for the Aged ................................................................................................................................................. 47
Office of the Chief Workforce Advisor ................................................................................................................ 48
Office of the State Long-Term Care Ombudsman ............................................................................................. 48
Virginia Department of Health Professions ......................................................................................................... 48
Virginia Health Care Association | Virginia Center for Assisted Living ......................................................... 50
Appendix H – Service Learning Requirements by Jurisdiction ............................................................51
Appendix I – Nursing Home Staffing Requirements by Jurisdiction ................................................. 66
Appendix J – CNA Responses to Dignity for the Aged ....................................................................... 73
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
E X E C U T I V E S U M M A RY
As a condition of state licensure, nursing homes are required to provide a sufficient number of nursing
staff to meet the assessed nursing care needs of its residents. Similarly, for those nursing homes participating
in the Medicare and Medicaid programs, federal regulations require facilities to have sufficient nursing staff to
address the number, acuity, and diagnoses of residents. The clinical workforce in Virginia—particularly certified
nurse aides (CNAs) and licensed practical nurses (LPNs)—has declined in recent years; as a result, all medical
care facilities, including nursing homes, have an increasingly smaller pool of qualified applicants from which to
hire. The availability of the clinical workforce directly impacts the quality of care provided to nursing home
residents.
The General Assembly directed the Virginia Department of Health (VDH) to convene a work group of
key stakeholders in order to “review and make recommendations on increasing the availability of the clinical
workforce for nursing homes in the Commonwealth.” VDH convened a work group that met eight times
between July and November 2020. The work group received numerous informational presentations and
received extensive written and oral comments. Through its discussions and deliberations, the work group
focused in particular on the following issues and topics within the context of the study mandate:
Education
Wages
Expansion of the existing workforce
Education. The work group identified the need to strengthen the educational pipeline that leads to careers
not just in the clinical workforce, but specifically the clinical workforce in nursing homes. Some
recommendations developed by the work group may be mutually exclusive (e.g., the multiple service learning
options), but the work group felt that adoption of any one option would be beneficial to increasing the
availability of the clinical workforce in nursing homes. The following recommendations are made:
1. Permit, but not require, local school boards to offer graduation credit for service learning in clinical
care in long term care settings. Service learning is an instructional strategy that combines meaningful
hands-on service to and for the benefit of the community with curriculum-based learning meeting
specified objectives defined by the local school board in consultation with the Virginia Department of
Health Professions (DHP) and VDH
2. Statewide offering of optional graduation credit for service learning in clinical care in long term care
settings. Service learning is an instructional strategy that combines meaningful hands-on service to and
for the benefit of the community with curriculum-based learning meeting specified objectives defined
by the Virginia Board of Education (VBOE) in consultation with DHP and VDH
3. Statewide offering of optional Fairfax County Public Schools model of hours-based service learning
(i.e., required for students in grades 6, 8, and 12, with optional diploma seal if additional hours are
completed) in clinical care in long term care settings. Service learning is an instructional strategy that
combines meaningful hands-on service to and for the benefit of the community with curriculum-based
learning meeting specified objectives defined by the VBOE in consultation with DHP and VDH
4. Require changes to nursing home regulations to permit volunteerism in nursing homes, with
supervision that includes orientation and training for volunteers consistent with the tasks assigned,
recording the type of tasks and time worked, and method by which a volunteer may contact supervisor
for immediate assistance
5. Require changes to nursing home regulations to permit service learning in nursing homes, with
supervision that includes orientation and training consistent with the tasks assigned, recording the type
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
of tasks and time worked, and method by which a learner may contact supervisor for immediate
assistance
6. Establish education and outreach programs for middle school and high school students to promote
career pathways in long term care
7. Funding for tuition of the Advanced Certification for CNAs upon conclusion of pilot program
8. Expand eligibility of Nurse Loan Repayment Program in Va. Code § 32.1-122.6:04 (also known as the
Mary Marshall Nursing Scholarship) to include CNAs
9. Fund the Nursing Scholarship and Loan Repayment Fund in Va. Code § 54.1-3011.2
Wages. The work group also recognized that one of the major challenges facing the current clinical
workforce is low wages, which leads to difficulty in adequately staffing nursing homes, which in turn leads to
burnout of existing staff. Some recommendations developed by the work group may be mutually exclusive (e.g.,
the multiple pay-for-performance programs), but the work group felt that adoption of any one option would
be beneficial to increasing the availability of the clinical workforce in nursing homes. The following
recommendations are made:
10. Establish financial relief program to support direct care nursing home employees by covering a
percentage of childcare or dependent care costs
11. Establish financial relief program to support direct care nursing home employees by covering a
percentage of transportation costs to include public transportation costs
12. Establish financial relief program to support direct care nursing home employees by covering a
percentage of living costs, which may include housing, transportation, childcare or dependent care,
utilities, or other categories of expenses as determined by the General Assembly
13. Increase wages for CNAs proportional to regional living wage standards, with living wage standards
derived from United For ALICE project data aggregated according to the local workforce board region
14. Increase wages for CNAs proportional to regional living wage standards, with living wage standards
derived from Massachusetts Institute of Technology (MIT) Living Wage Calculator aggregated
according to the local workforce board region
15. Increase minimum wage proportional to regional living wage standards, with living wage standards
derived from United For ALICE project data aggregated according to the local workforce board region
16. Increase minimum wage proportional to regional living wage standards, with living wage standards
derived from MIT Living Wage Calculator aggregated according to the local workforce board region
17. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived
from United For ALICE project data aggregated according to the local workforce board region) and
mandating rate increases are passed on to direct care workers by implementing a wage pass-through
program
18. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived
from MIT Living Wage Calculator aggregated according to the local workforce board region) and
mandating rate increases are passed on to direct care workers by implementing a wage pass-through
program
19. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards
(derived from United For ALICE project data aggregated according to the local workforce board
region) and mandating rate increases are passed on to direct care workers by implementing a wage
pass-through program
20. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards
(derived from MIT Living Wage Calculator aggregated according to the local workforce board region)
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
and mandating rate increases are passed on to direct care workers by implementing a wage pass-through
program
21. Pay for performance program through the Virginia Department of Medical Assistance Services
(DMAS) to provide additional reimbursement to facilities meeting minimum staff-to-resident ratios
and meeting minimum quality of care standards as determined by DMAS, with such threshold ratios
for additional reimbursement increasing every biennium for three biennia
22. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum staff-to-resident ratios and meeting minimum quality of care standards as
determined by DMAS, with such threshold ratios for additional reimbursement beginning at 12-to-1
and increasing to 6-to-1 over for four biennia
23. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum hours of nursing care per resident, with such threshold hours for additional
reimbursement increasing every biennium for three biennia
24. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum hours of nursing care per resident and meeting minimum quality of care standards
as determined by DMAS, with such threshold hours for additional reimbursement beginning at 3.5
hours and increasing to 4.1 hours over for three biennia
Expansion of the existing workforce. The work group examined ways to expand the clinical workforce in nursing
homes, both now and in the future, by investigating means and methods to incentivize the inclusion of veterans,
persons with disabilities, and other groups. The work group also looked at ways to incentivize the existing
clinical workforce to remain in nursing homes. The following recommendations are made:
25. Creating a workforce program similar to Virginia Values Veterans (V3) Program for people with
disabilities to increase employment opportunities and promote economic development by training and
certifying organizations in disability workforce best practices
26. Require changes to nursing home regulations to permit care by non-credentialed individuals in the
Military Medics and Corpsmen (MMAC) program
27. Civilian credentialing/licensing reciprocity so state regulatory bodies recognize civilian equivalency of
certain military allied health specialties
28. Civilian educational credits for statewide standardized recognition of military medical education and
awarding of equivalent credit hours
29. Funding for awareness campaign for MMAC Program and the healthcare employment opportunities
provided by the program
30. State version of the federal work opportunity income tax credit for private-sector businesses that hire
individuals who have consistently faced significant barriers to employment, as determined by the
General Assembly
31. State income tax credit for CNAs, LPNs, and registered nurses (RNs) working at licensed nursing
homes and certified nursing facilities
32. State income tax credit for for-profit nursing homes based on expenditures aimed at providing access
to employees with disabilities
33. Tax relief program for not-for-profit nursing homes that would allow them to offset part of their
payroll tax for expenditures aimed at providing access to employees with disabilities
34. Direct Joint Commission on Health Care to conduct a study on direct care staff recruitment
and retention, workplace culture improvements, and internal leadership development in nursing homes
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
I N T ROD U C T I ON
The Division of Long Term Care Services in the Virginia Department of Health’s (VDH) Office of
Licensure and Certification (OLC) is the unit responsible for the state licensure and inspection of nursing
homes1 and for conducting federal surveys of certified nursing facilities.2
A certified nursing facility is one that has chosen to participate in the Medicare and/or Medicaid programs,
and therefore, be subject to the conditions of participation (COPs) for those programs. Certified nursing
facilities must comply with federal COPs and state licensure regulations. Nursing homes are not subject to
federal COPs. As of October 27, 2020, there are 283 nursing homes and 275 certified nursing facilities in
Virginia. Eight nursing homes are currently licensed, but not participating in Medicare and/or Medicaid; all
residents of these non-participating nursing homes fund their care through private pay arrangements.
Resident care in nursing homes and certified nursing facilities is provided primarily by certified nurse aides
(CNAs), licensed practical nurses (LPNs), and registered nurses (RNs). Each nursing home and certified nursing
facility must have sufficient clinical staff to meet the needs of each resident.3
STUDY MANDATE
The General Assembly, in Chapter 932 of the 2020 Acts of Assembly, directed the Virginia Department of
Health (VDH) to convene a work group of key stakeholders in order “review and make recommendations on
increasing the availability of the clinical workforce for nursing homes in the Commonwealth” (Appendix A).
WORK GROUP ACTIVITIES
In response to the legislative mandate, the Office of Licensure and Certification (OLC) in VDH convened
a 32-member work group representing a broad range of perspectives and expertise. The work group held eight
meetings during 2020: on July 6, July 20, August 4, August 17, August 31, September 25, September 30, and
November 9.
JULY 6 MEETING
The work group reviewed the mission of the Chapter 932 work group set forth by the 2020 General
Assembly. In addition, the current state of Virginia’s nursing home workforce was reviewed and a preliminary
road map for the work group was produced. The work group discussed opportunities to leverage civic
engagement requirements in public schools as a means to market the value of nursing home jobs and the need
to explore additional policy recommendations to enhance the nursing home workforce.
JULY 20 MEETING
The work group revised the Chapter 932 work group road map to focus on educational pipelines, training
curriculum, student debt, payer mix, reimbursement rates, and financial incentive programs. Virginia’s public
school service learning requirements were reviewed in addition to multiple various workforce development and
1 Va. Code § 32.1-123 defines nursing home as “any facility or any identifiable component of any facility licensed pursuant
to this article in which the primary function is the provision, on a continuing basis, of nursing services and health-related
services for the treatment and inpatient care of two or more non-related individuals, including facilities known by varying
nomenclature or designation such as convalescent homes, skilled nursing facilities or skilled care facilities, intermediate
care facilities, extended care facilities and nursing or nursing care facilities.”
2 Va. Code § 32.1-123 defines certified nursing facility as “any skilled nursing facility, skilled care facility, intermediate care
facility, nursing or nursing care facility, or nursing home, whether freestanding or a portion of a freestanding medical care
facility, that is certified as a Medicare or Medicaid provider, or both, pursuant to § 32.1-137.”
3 See 12VAC5-371-210(B) and 42 C.F.R. § 483.35.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
student loan repayment programs. Members of the public implored the work group to focus on the drivers of
poor nursing home quality outcomes, such as low nurse aide wages and regulatory accountability.
AUGUST 4 MEETING
The work group discussed opportunities to enhance nursing home staff curricula for special populations
by developing courses that focus on engaging with residents who are blind, deaf, and/or hard of hearing as well
as the need to develop programs for blind, deaf, and/or hard of hearing staff. Programs supporting the
integration of veterans into the civilian health care workforce were discussed as were the payer mix for Virginia’s
certified nursing facilities, full-time equivalents (FTEs), labor costs, revenues, profit margins, and
reimbursement rates. Tax incentive programs that nursing homes can further leverage to support staffing
recruitment and retention were presented.
AUGUST 17 MEETING
William A. Hazel Jr., MD provided an overview of the Claude Moore Scholars Healthcare Education
Program, which provides funds to public school systems and institutions of higher education to develop and
maintain Career and Technical Education (CTE) programs and Medicaid staff discussed Medicaid rate setting,
sources of funding, and incentive programs. Meaghan Green, the Special Assistant to Governor Northam’s
Chief Workforce Advisor, presented on nursing and other long-term care facility workforce trends as well as
opportunities to recruit the workforce impacted by the COVID-19 pandemic into high-need long-term care
settings. The work group reviewed resident and staffing demographics of Virginia’s nursing homes as well as
the payer mix for residents. Additionally, the financial and operational impacts of COVID-19 on Virginia’s
nursing homes and potential opportunities to address workforce gaps, including temporary nurse aide training
programs, FastForward Virginia, and scholarship programs.
AUGUST 31 MEETING
The work group reviewed research conducted by VDH staff highlighting strategies other states have
utilized in mandating staffing ratios in nursing homes and data comparing ratios reported to the U.S. Centers
for Medicare and Medicaid Services (CMS), hospitalizations per 1,000 long-stay resident days, CNA hourly
mean wages, total CNA workforce, employment per 1,000 jobs, and Medicaid expenditures per aged enrollee.
Additionally, potential work group recommendations as submitted by members were reviewed.
SEPTEMBER 25 MEETING
The work group conducted an initial review of the 17 recommendations that had been produced by the
work group to date. It was requested by the work group that revisions be made to the draft recommendations
and that another meeting be held to finalize recommendations.
SEPTEMBER 30 MEETING
Each of the 32 potential recommendations produced by the work group were put forward for final review
and revision, after which time recommendation voting instructions were provided.
NOVEMBER 9 MEETING
The work group reviewed the draft report and recommendations in addition to next steps for report
submission.
REPORT OUTLINE
Following the discussion of the study mandate and the activities of the clinical workforce work group,
the report provides an overview of Virginia’s clinical workforce and the current regulatory and statutory
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
requirements for staffing. A description of other states’ minimum nursing home staffing requirements is
included. The report also describes the star rating system utilized by the CMS and the specific ratings related to
the clinical workforce.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
V I RG I N I A’ S C L I N I C A L WO R K F ORC E F O R N U R S I N G H OM E S
STATE OF THE WORKFORCE
As noted in the Introduction, the clinical workforce needs for Virginia’s nursing home residents rely
primarily upon a mix of CNAs, LPNs, and RNs. The Virginia Department of Health Professions (DHP), which
is composed of the numerous boards responsible for licensing and oversight of health professionals, routinely
surveys health professionals when they renew their licenses and certifications. This surveying function is carried
out by DHP’s Healthcare Workforce Data Center (HWDC). The HWDC produces white papers and numerous
data products, such as the profession reports that provide a statewide look at the healthcare workforce on a
profession-by-profession basis. The HWDC produces regular reports on the 62 professions regulated by DHP
and the most recent profession reports are from 2019.
HWDC’s Virginia’s Certified Nurse Aide Workforce: 2019 report indicated that there are 60,272 CNAs in
Virginia, representing 50,584 FTEs.4 It is estimated that 56,870 CNAs worked at least part of the year in the
state or intend to return to work as a CNA in the future.5 Nursing homes employ 29% of the state’s CNAs as
their primary place of employment and 18% as a secondary place of employment.6 When compared with data
from five years ago, there has been a 2% decline in the number of CNAs in the state. 7 However, in spite of
this decline, the number of CNAs who are actively in the workforce has increased by 7%, boosting the number
of FTEs by 12%.8 CNAs in Virginia are 94% female and their median age is 38, down from 39 five years ago.9
The rate of involuntary unemployment over the past five years has fallen dramatically from 9% to 3%. 10
Three quarters of CNAs receive at least one employer-sponsored benefit including 54% who have access to
health insurance.11 The median hourly wage for Virginia’s CNAs has increased from $11-$12 five years ago to
$13-$14 per hour in 2019.12 The pay rate ranges from less than $7.50 per hour to over $15 per hour.13 A
comparison of the hourly pay rate between 2014 and 2019 is show below in Figure 1.
4 FTEs are defined as those persons working 2,000 hours per year or 40 hours per week for 50 weeks. Elizabeth A. Carter,
ed., “Virginia’s Certified Nurse Aide Workforce: 2019” (Healthcare Workforce Data Center, October 2019),
https://www.dhp.virginia.gov/media/dhpweb/docs/hwdc/nurse/1401CNA2019.pdf, 4.
5 Ibid, 2.
6 Ibid, 13.
7 Ibid, 2.
8 Ibid.
9 Ibid.
10 Ibid.
11 Ibid.
12 Ibid, 2.
13 Ibid, 10.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
5-Year Comparison of CNA Hourly Wages
$15.00 or more
$14.00 to $14.99
$13.00 to $13.99
$12.00 to $12.99
$11.00 to $11.99
$10.00 to $10.99
$9.00 to $9.99
$8.00 to $8.99
$7.50 to $7.99
Less than $7.50
0 5 10 15 20 25 30
2014 2019
Figure 1: 5-Year Comparison of CNA Hourly Wages14
HWDC’s Virginia’s Licensed Practical Nurse Workforce: 2019 report indicated that Virginia has licensed 29,500
LPNs, representing 23,974 FTEs.15 It is estimated that 26,725 LPNs worked at least part of the year in the state
or intend to return to work as an LPN in the future.16 Long-term care facilities or nursing homes employ 26%
of the state’s LPNs as their primary place of employment with 33% reporting these facilities as a secondary
place of employment.17 When compared with data from five years ago, there has been a 5% decline in the
number of licensed LPNs in the state resulting in a 4% decrease in the LPN workforce and a 4% decrease in
FTEs.18 LPNs in Virginia are 95% female and their median age is 46.19
The median debt burden of an LPN is $20,000 to $30,000, up from $10,000 to $20,000 five years ago.20
The median annual income is $40,000 to $50,000, which is an increase from $30,000 to $40,000 five years ago.21
Pay ranges from less than $20,000 annually to $100,000 or more.22 The rate of involuntary unemployment for
LPNs over the same period has fallen from 3% to 2%.23 Seventy-nine percent of LPNs have access to at least
one employer-sponsored benefit including 62% who have health insurance.24
14 Ibid and Elizabeth A. Carter, ed., “Virginia’s Certified Nurse Aide Workforce: 2014” (Healthcare Workforce Data
Center, January 2015), https://www.dhp.virginia.gov/media/dhpweb/docs/hwdc/nurse/1401CNA_2014.pdf, 10.
15 Elizabeth A. Carter, ed., “Virginia’s Licensed Practical Nurse Workforce: 2019” (Healthcare Workforce Data Center,
October 2019), https://www.dhp.virginia.gov/media/dhpweb/docs/hwdc/nurse/0002LPN2019.pdf, 1.
16 Ibid, 2.
17 Ibid, 16.
18 Ibid, 2.
19 Ibid, 16.
20 Ibid, 2.
21 Ibid.
22 Ibid, 8.
23 Ibid, 2.
24 Ibid.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
HWDC’s Virginia’s Registered Nurse Workforce: 2019 report indicated that Virginia has 112,053 RNs
representing 81,369 FTEs.25 It is estimated that 94,384 RNs worked at least part of the year in the state or
intend to return to work as an RN in the future.26 Long-term care facilities or nursing homes employ 4% of the
state’s RNs as their primary place of employment and 6% as a secondary place of employment.27 The number
of RNs licensed in Virginia has increased by 11% over the last five years, representing a 14% increase in the
RN workforce and a 13% increase in FTEs.28 RNs in Virginia are 93% female and their median age is 46, 29
falling from 48 five years ago.30
The median debt burden of an RN is $30,000 to $40,000, an increase from $20,000 to $30,000 five years
ago, and the median annual income is $60,000 to $70,000 which is an increase from $50,000 to $60,000 during
the same time.31 Pay ranges from less than $10,000 to more than $120,000 annually.32 The rate of involuntary
unemployment for RNs over the same period has fallen from 2% to 1%.33 Eighty-four percent of RNs have
access to at least one employer-sponsored benefit, including 66% who have health insurance through their
employer.34
CMS FIVE-STAR RATINGS FOR WORKFORCE
CMS has created for the public the Nursing Home Compare site that provides information about every
certified nursing facility in the country.35 This comparison function includes the Five-Star Quality Rating
System, which assists residents, families, and caregivers to more easily compare nursing homes and to obtain
answers about them.36 The Five-Star Quality Rating System rates each nursing home with one to five stars, with
five stars representing above average quality ratings and one star representing those below average. Each
nursing home is assigned a single rating overall with separate ratings for health inspections, staffing, and quality
measures.37
The Nursing Home Compare Five-Star Quality Rating System user’s guide describes, in relevant part, how
it evaluates staffing:38
25 Elizabeth A. Carter, ed., “Virginia’s Registered Nurse Workforce: 2019” (Healthcare Workforce Data Center, October
2019), https://www.dhp.virginia.gov/media/dhpweb/docs/hwdc/nurse/0001RN2019.pdf, 1.
26 Ibid, 2.
27 Ibid, 16.
28 Ibid, 2.
29 Ibid, 5.
30 Ibid, 2.
31 Ibid.
32 Ibid, 8.
33 Ibid, 2.
34 Ibid.
35 “Medicare Nursing Home Compare Overview.” U.S. Centers for Medicare and Medicaid Services, 2020.
https://www.medicare.gov/NursingHomeCompare/About/howcannhchelp.html.
36 “What Information Can I Get About Nursing Homes?” U.S. Centers for Medicare and Medicaid Services, 2020.
https://www.medicare.gov/NursingHomeCompare/About/nhcinformation.html.
37 Ibid.
38 U.S. Centers for Medicare and Medicaid Services. 2015. “Design for Nursing Home Compare Five-Star Quality Rating
System: Technical Users’ Guide.” https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/usersguide.pdf.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Staffing - Measures based on nursing home staffing levels: Ratings on the staffing domain are based on two
measures: 1) Registered nurse (RN) hours per resident per day; and 2) total nurse staffing (the sum of RN,
licensed practical nurse (LPN), and nurse aide) hours per resident per day. Other types of nursing home staff,
such as clerical or housekeeping staff, are not included in the staffing rating calculation. The staffing measures
are derived from data submitted each quarter through the Payroll-Based Journal (PBJ) System…
Section 6106 of the Patient Protection and Affordable Care Act amended the Social Security Act to require
certified nursing facilities to electronically submit direct care staffing information based on payroll and other
auditable data.39 The data, when combined with census information, can then be used to report on the level of
staff in each nursing home, as well as employee turnover and tenure, which can impact the quality of care
delivered.
Current Virginia regulatory requirements for nursing home staffing defines the nursing supervisor and their
duties and requires the facility to provide qualified nurses and CNAs on all shifts in sufficient number to meet
the assessed needs of all residents.40 Likewise, CMS’s staffing COP41 requires certified nursing facilities to “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…” There are other jurisdictions that have
more specific requirements (Appendix I). As of the date of this report, out of the 286 certified nursing facilities
in Virginia,42 on the staffing metric, 40 received 1 Star indicating much below average, 84 received 2 Stars
indicating below average, 66 received 3 Stars indicating average, 53 received 4 Stars indicating above average,
and 35 received 5 stars indicating much above average. A visual representation of this distribution is shown
below in Figure 2.
CMS Star Rating for Virginia Certified Nursing Facilities
1 Star 5 Stars
14% 13%
4 Stars
19%
2 Stars
30%
3 Stars
24%
Figure 2: CMS Star Rating for Virginia Certified Nursing Facilities
39 See Patient Protection and Affordable Care Act of 2010, H.R. 3590, 111th Cong. § 6106 (2010) and 42 C.F.R. § 483.70(q).
40 See 12VAC5-371-210.
41 See 42 C.F.R. § 483.35.
42 Two facilities were too new to rate and 20 facilities did not have data available regarding staffing
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
P O L I C Y R E C OM M E N DA T I O N S
The work group considered 34 potential recommendations, of which 21 were adopted with an outright
majority vote of Support and 13 were adopted after abstention votes were accounted for.43 Each stakeholder
organization or agency was afforded one vote per recommendation, and a recommendation was approved for
inclusion in the work group’s report if a simple majority voted in support of the recommendation. The results
of the stakeholders’ votes may be found in Appendix E. If a stakeholder opposed a recommendation, the
stakeholder was also given the opportunity to explain its opposition in writing; these written comments are
reproduced, in full, in Appendix F.
No recommendation received a majority “Oppose” vote, though there are several recommendations where
the majority vote was “Abstain”; those recommendations that received a majority “Abstain” vote were
otherwise supported by a majority of the stakeholders. The outcome of each vote is indicated beside the
recommendations, with “Y” indicating a yes vote, “N” indicating a no vote, and “A” indicating an abstention.
EDUCATION-RELATED RECOMMENDATIONS
The work group recognizes that part of the clinical workforce shortage in nursing homes is due to a less-
than-robust pipeline of potential direct care workers. To address this pipeline issue, the work group examined
topics that could expose students to the career opportunities in direct care work in the long term care and
financial barriers in education to either enter the workforce or to advance with additional learning opportunities.
SERVICE LEARNING AND VOLUNTEERISM
A majority of jurisdictions have adopted service learning as either a requirement or an optional credit for
graduation (Appendix H). Service learning is different from volunteerism or community service in that service
learning is part of a structured curriculum with specified objectives.
Service learning is distinguished from community service or other volunteerism in that it is tied to
curriculum and standards, either set at the state or local level. Service learning is often framed as an instructional
strategy to increase student achievement, increase student civic engagement, prepare students for the workplace,
or some combination of all three.44 The work group discussed various service learning implementations by
jurisdiction. A small minority of jurisdictions45 set service learning requirements as a graduation requirement
for all students. Many more jurisdictions have service learning as an optional jurisdiction-wide graduation credit
that all students can pursue, with varying degrees of discretion granted to local school boards to set standards
and objectives for service learning.
A final option for service learning gives discretion to local school boards to both offer the graduation credit
and to set standards and objectives for service learning. This option has already been implemented by Colorado,
Florida, Iowa, Rhode Island, Tennessee, and Wisconsin. Half of these states utilize the service learning
requirement as potential endorsement on the high school diploma or academic award, whereas the other half
utilize it as a potential graduation requirement. In Virginia, Fairfax County Public Schools (FCPS) has launched
an hours-based service learning model and is documenting its students’ successful completion of the program
43 Stakeholders were given the options of “Support”, “Oppose”, or “Abstain” when voting on individual
recommendations. Some recommendations received more Abstain votes than Support or Oppose votes, but once the
Abstain votes were accounted for, the recommendations received more Support than Oppose votes.
44 Baumann, Paul. “50-State Comparison: Service-Learning/Community Service as a Strategy for Fostering Student
Outcomes.” Education Commission of the States. National Center for Learning and Civic Engagement, January 1, 2014.
http://ecs.force.com/mbdata/mbquest3RTE?Rep=SL1303.
45 See Md. Code Regs. 13A.03.02.06 and D.C. Mun. Regs. tit. 5-E § 2203.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
through the electronic x2vol software.46 This program calls for a minimum number of service hours in Grades
6, 8, and 9 through 12,47 as outlined below:
Grade 6: 5 hours
Grade 8: 15 hours
Grades 9–12: 40 hours, though students are encouraged to spread out this requirement so that they are
completing 10 hours annually.
By completing these hours, FCPS offers a FCPS service learning cord.48 FCPS also offers a diploma seal
for excellence in civics education for those high school students completing more than 50 hours.49 FCPS’s
service learning is built upon the principles of connection with curriculum, authenticity, intentionality,
reflection, impact to the community, and applicability to the student’s interests and career goals.50
The work group discussed all of the service learning models and as part of that discussion, rejected
consideration of a statewide requirement for service learning as too prescriptive and restrictive. The service
learning recommendations that the work group voted upon are mutually exclusive; for example,
Recommendation 1 leaves service learning to the discretion of local school boards whereas Recommendation
2 does not and instead gives the student the choice to pursue the optional graduation credit. The work group
recognizes this incompatibility, but based on the votes, felt that the recommendations below represent a
spectrum of choices that the General Assembly may utilize if it wishes to implement service learning in Virginia.
The work group also discussed that if a service learning recommendation were to be adopted by the General
Assembly or in the alternative, the General Assembly wished to encourage volunteerism by students and other
members of the community in nursing homes, the nursing home regulations would need to be updated as
outlined in Recommendations 4 and 5 below.
No. Recommendation Voting Result
1 Permit, but not require, local school boards to offer graduation credit for 11Y - 1N - 5A
service learning in clinical care in long term care settings. Service learning is an
instructional strategy that combines meaningful hands-on service to and for the
benefit of the community with curriculum-based learning meeting specified
objectives defined by the local school board in consultation with DHP and
VDH
2 Statewide offering of optional graduation credit for service learning in clinical 11Y - 1N - 5A
care in long term care settings. Service learning is an instructional strategy that
combines meaningful hands-on service to and for the benefit of the
community with curriculum-based learning meeting specified objectives
defined by the Virginia Board of Education (VBOE) in consultation with
DHP and VDH
3 Statewide offering of optional Fairfax County Public Schools model of hours- 9Y - 1N - 7A
46 “Service Learning.” Fairfax County Public Schools, 2020. https://www.fcps.edu/activities/service-learning.
47 Ibid.
48 “Service Learning.” W.T. Woodson High School, 2020. https://woodsonhs.fcps.edu/student-life-activities/service-
learning.
49 This diploma seal is available to any Virginia high school student who completes 50 or more volunteer hours, in
addition to other criteria. “Graduation (Diploma) Seals of Achievement.” Virginia Department of Education, 2020.
https://www.doe.virginia.gov/instruction/graduation/diploma_seals/index.shtml.
50 “Service Learning.” Fairfax County Public Schools, 2020. https://www.fcps.edu/activities/service-learning.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
based service learning (i.e., required for students in grades 6, 8, and 12, with
optional diploma seal if additional hours are completed) in clinical care in long
term care settings. Service learning is an instructional strategy that combines
meaningful hands-on service to and for the benefit of the community with
curriculum-based learning meeting specified objectives defined by the VBOE
in consultation with DHP and VDH
4 Require changes to nursing home regulations to permit volunteerism in 10Y - 2N - 5A
nursing homes, with supervision that includes orientation and training for
volunteers consistent with the tasks assigned, recording the type of tasks and
time worked, and method by which a volunteer may contact supervisor for
immediate assistance
5 Require changes to nursing home regulations to permit service learning in 12Y - 1N - 4A
nursing homes, with supervision that includes that includes orientation and
training consistent with the tasks assigned, recording the type of tasks and
time worked, and method by which a learner may contact supervisor for
immediate assistance
STUDENT OUTREACH
During the work group’s meetings, representatives from LeadingAge Virginia51 and the Claude Moore
Charitable Foundation52 spoke about the importance of early engagement with students to cultivate and
encourage interest in long term care settings. LeadingAge Virginia described its efforts with a poster campaign
pilot program for elementary students, based on the successful “Careers that Love You Back” poster campaign
created by LeadingAge Ohio,53 which promotes student awareness of 21 careers in the aging services workforce
sector. The pilot program consists of both posters and a teacher’s guide that has sample lesson plans, classroom
activities, and other engagement recommendations.54 Dr. William H. Hazel, Jr. with the Claude Moore
Charitable Foundation also spoke about the Claude Moore Scholars Program, which “provides local school
systems with grant funds to establish healthcare education programs for high school students that will meet
local, regional, and state-wide workforce needs.”55 Since LeadingAge Virginia’s work was presently a pilot
program aimed at elementary students and the Claude Moore Scholars Program was involved in seven school
districts,56 the work group discussed and considered the need for statewide education and outreach programs
promoting long term care careers to address the gaps between these two existing efforts.
51 LeadingAge Virginia is an association of not-for-profit aging services organizations serving residents and clients through
life plan/continuing care retirement communities, senior housing, assisted living, nursing homes, adult day centers and
home and community based services.
52 The Claude Moore Charitable Foundation is an organization that supports programs and partnerships aimed at
increasing academic competence and encouraging leadership abilities, with an emphasis on the underprivileged.
53 “Careers That Love You Back.” LeadingAge Ohio, 2019, leadingageohio.org/aws/LAO/pt/sp/posters.
54 A Teacher’s Guide to Careers That Love You Back. LeadingAge Ohio, 2019,
leadingageohio.org/aws/LAO/asset_manager/get_file/328050?ver=5831.
55 “Public School Systems K-12.” Claude Moore Charitable Foundation, 2020,
https://claudemoorefoundation.org/claude-moore-scholars-program/k-12-school-systems/
56 The school systems that the Claude Moore Charitable Foundation is currently partnered with are Loudoun County
Public Schools, Fairfax County Public Schools, Winchester City Public Schools, Petersburg City Public Schools,
Chesterfield County Public Schools, Halifax County Public Schools, and Prince William County Public Schools.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
No. Recommendation Voting Result
6 Establish education and outreach programs for middle school and high school 12Y - 1N - 4A
students to promote career pathways in long term care
EDUCATIONAL FUNDING
Part of the work group’s discussion involved funding for education opportunities of the clinical workforce.
Representatives from LeadingAge Virginia spoke about its grant-funded educational pilot program consisting
of both clinical and classroom coursework for CNAs that helps them meet the criteria to apply for the
Advanced Nurse Aide certification. This program has been developed in collaboration with Blue Ridge
Community College (BRCC) and Sunnyside Retirement Community, and in consultation with DHP’s Board of
Nursing.57 Thirty students will receive scholarships to take the course through BRCC, broken down as ten
students over three semesters.58 This educational program is designed to teach CNAs additional skills to
improve care and well-being of nursing home residents and to create a career path and advancement ladder for
better staff retention and to decrease burnout.
As noted, the scholarship for this program is grant funded, specifically through the Civil Monetary Penalty
(CMP) Fund. The CMP Fund is a collection of monetary penalties that CMS may impose against certified
nursing facilities, for either the number of days or for each instance a facility is not in substantial compliance
with one or more Medicare and Medicaid COPs. Regardless of jurisdiction, CMP funds are used for projects
that directly benefit individuals residing in a certified nursing facility through protecting and improving
residents’ quality of life and care. However, the CMP Fund projects cannot exceed three years, and LeadingAge
Virginia representatives explained that while they would like to expand the pilot program to other educational
institutions, presently additional funding for full or partial scholarships has not been secured.
Representatives from Virginia Board of Nursing and VDH’s Office of Health Equity touched upon the
fact that two statutory educational funding programs already exist. The Nurse Loan Repayment Program, which
is also known as the Mary Marshall Nursing Scholarship, was established by Chapter 188 (2001 Acts of
Assembly). This program is funded by fees collected by DHP’s Board of Nursing and both LPNs and RNs
may apply for the scholarship. CNAs are presently not eligible for this scholarship program.59
The Nursing Scholarship and Loan Repayment Fund was established by Chapter 699 (1991 Acts of
Assembly). Unlike the Mary Marshall Nursing Scholarship, CNAs are already eligible to partake in this program,
per the amendments in Chapters 240 and 254 (2000 Acts of Assembly). These 2000 amendments expanded
eligibility to RNs, LPNs, and CNAs who agree to work in Virginia long-term care facilities.60 However, the
Nursing Scholarship and Loan Repayment Fund is not fee-funded and is instead reliant on appropriations from
the General Fund. Presently, there are no General Fund appropriations for this program, which means there is
no money available to distribute.
No. Recommendation Voting Result
7 Funding for tuition of the Advanced Certification for CNAs upon conclusion 10Y - 1N - 6A
of pilot program
57 “Advanced Certified Nurse Aide Program.” LeadingAge Virginia, 2020.
https://leadingagevirginia.org/mpage/AdvancedCNAHome.
58 Due to the COVID-19 pandemic, the start of the program has been delayed to March 2021.
59 See Va. Code § 32.1-122.6:04(A).
60 Per 12VAC5-507-10, ““Long-term care facility” means a certified nursing facility or nursing home as defined in § 32.1-
123 of the Code of Virginia.”
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
8 Expand eligibility of Nurse Loan Repayment Program in Va. Code § 32.1- 12Y - 1N - 4A
122.6:04 (also known as the Mary Marshall Nursing Scholarship) to include
CNAs
9 Fund the Nursing Scholarship and Loan Repayment Fund in Va. Code § 54.1- 11Y - 1N - 5A
3011.2
WAGE-RELATED RECOMMENDATIONS
The work group also focused on topics relevant to those persons already part of the clinical workforce in
nursing homes. These topics included low wages for direct care staff, particularly CNAs, and how the low wages
were tied to Medicaid reimbursement rates. The work group also considered topics touching upon what other
financial relief could be offered to direct care staff that was not wage-specific.
FINANCIAL RELIEF PROGRAMS
Meaghan Green with the Office of the Chief Workforce Advisor discussed trends and opportunities for
the long-term care workforce with the work group. She also presented wage data showing that in many Virginia
communities CNAs make less than living wages. Her presentation led to the conclusions that pay increases,
incentives, and additional workforce supports would boost nursing home staff recruitment and retention. As
part of that discussion, Ms. Green indicated that financial relief programs that target dependent care or
childcare, transportation, and other expenses could be a solution to the challenges faced by the nursing home
workforce during the COVID-19 pandemic. Based on Ms. Green’s presentation and the discussion that
followed, the work group voted upon three recommendations related to financial relief, with Recommendation
12 placing the discretion on the General Assembly to decide the categories of expenses to be targeted by a
proposed financial relief program.
No. Recommendation Voting Result
10 Establish financial relief program to support direct care nursing home 9Y - 1N - 7A
employees by covering a percentage of childcare or dependent care costs
11 Establish financial relief program to support direct care nursing home 9Y - 1N - 7A
employees by covering a percentage of transportation costs to include public
transportation costs
12 Establish financial relief program to support direct care nursing home 7Y - 2N - 8A
employees by covering a percentage of living costs, which may include housing,
transportation, childcare or dependent care, utilities, or other categories of
expenses as determined by the General Assembly
MINIMUM WAGE
In a letter to the work group from the Virginia Health Care Association/Virginia Center for Assisted
Living—which is Virginia’s largest association representing long term care—President and CEO Keith Hare
called attention to wages and underfunding of nursing services by Virginia Medicaid.61 He stated that addressing
these concerns will be critical to arriving at meaningful solutions to nursing home staffing.62 He also noted that
61 Hare, Keith. Letter to The Honorable Jennifer Kiggans, Dr. Carole Pratt, and Rebekah Allen. “Ch. 932 (2020 Acts of
Assembly) Work Group.” Richmond, VA, August 4, 2020.
62 Ibid.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
wages are a major portion of nursing care costs with more than 60% of Virginia’s nursing home residents
relying on Medicaid for their care.63 Mr. Hare also made a presentation to the work group about an overview
of resident and staffing data from the association’s membership along with payer mix for residents.
The work group spent much time discussing the wage situation for direct care staff both before and after
the presentations by Mr. Hare and Ms. Green (noted in the prior section above). While recommendations
addressing the relationship between Medicaid reimbursement and wages are discussed in the next section, the
work group discussed other recommendations that would directly impact wages. As Ms. Green had noted
during her presentation, CNAs in Virginia often receive wages that are less than the living wage for the region
in which they live. The work group discussed recommendations that would mandate a minimum wage and how
to regionalize that wage amount. The work group examined the living wage data available for Virginia from
both United for ALICE64 and the Massachusetts Institute of Technology (MIT) Living Wage Calculator.
United for ALICE is a United Way program that provides statistics, tools, and data available for every
Virginia locality on living wages.65 According to United for ALICE’s most recent report, 39% of Virginia
households struggled to make ends meet, with 10% of households living below the Federal Poverty Level and
29% were ALICE, which means they are “above the FPL, but not enough to afford basic household
necessities.”66 United for ALICE provides three basic budgets—Household Survival, Senior Survival, and
Household Stability67—for each Virginia locality and the wage needed to cover the budget.
The MIT Living Wage Calculator similarly breaks down data for Virginia by locality, allowing stakeholders
and policymakers to estimate a community’s or region’s estimated cost of living based on usual expenses and
allowing employers to determine a wage that will meet the standard of living.68 The MIT Living Wage Calculator
splits out living wage calculations according to the number of children in the household and the number of
working adults. The work group did not find one data source to be superior to the other, but felt that specifying
the data source in the recommendation was important, so two versions of the wage recommendations were
voted upon
While the work group formulated recommendations specific to CNAs, there was concern that such a
narrow recommendation may face significant political headwinds. In light of this, the work group also voted
upon broader minimum wage proposals that were still regionalized according to data from either United for
ALICE or the MIT Living Wage Calculator.
The work group chose to base its regions on the local workforce boards that oversee local workforce
development areas (LWDAs). There are 15 LWDAs in Virginia,69 which are overseen by local workforce boards
that are appointed by the County Executive to align employment and training programs into a comprehensive
system.70 In collaboration with the Virginia Employment Commission and Virginia Career Works, they help
collect the latest market information including wage data, local area unemployment statistics, and occupational
employment statistics, among other data.
63 Ibid.
64 “ALICE” is defined as Asset Limited, Income Constrained, Employed.
65 “ALICE Project ‒ Virginia.” United Way of Northern New Jersey. 2020. https://www.unitedforalice.org/virginia.
66 Abrahamson, Andrew, Ashley Anglin, Catherine Connelly, Max Holdsworth, Dan Treglia, and Stephanie Hoppes.
2020. “ALICE in Virginia: A Financial Hardship Study.” United for ALICE. United Way of Northern New Jersey.
https://www.unitedforalice.org/Attachments/AllReports/2020ALICEReport_VA_FINAL.pdf
67 Ibid, 2.
68 Glasmeier, Amy K. “About the Living Wage Calculator.” Massachusetts Institute of Technology. 2020.
https://livingwage.mit.edu/
69 “Local Workforce Development Areas.” Virginia Employment Commission, 2020.
https://virginiaworks.com/Portals/200/Publications/LWDAs/Maps/LWDA%20Regions.pdf
70 “FAQ.” Virginia Career Works, 2020. https://virginiacareerworks.com/faq/.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
No. Recommendation Voting Result
13 Increase wages for CNAs proportional to regional living wage standards, with 9Y - 1N - 7A
living wage standards derived from United For ALICE project data aggregated
according to the local workforce board region
14 Increase wages for CNAs proportional to regional living wage standards, with 7Y - 0N - 10A
living wage standards derived from MIT Living Wage Calculator aggregated
according to the local workforce board region
15 Increase minimum wage proportional to regional living wage standards, with 7Y - 1N - 9A
living wage standards derived from United For ALICE project data aggregated
according to the local workforce board region
16 Increase minimum wage proportional to regional living wage standards, with 5Y - 0N - 12A
living wage standards derived from MIT Living Wage Calculator aggregated
according to the local workforce board region
MEDICAID REIMBURSEMENT
As mentioned earlier in this report, Medicaid reimbursement makes up a significant portion of many
nursing homes’ payer mix and has a direct impact on what wages can be paid to staff. Several representatives
from the Virginia Department of Medical Assistance Services (DMAS)—which is Virginia's Medicaid agency—
presented to the work group about how Medicaid reimbursement is determined. DMAS sets rates using the
Nursing Facility Price-Based Methodology71 and several data sources. The current per diem rate that a facility
receives for a resident funded by Medicaid is broken down into approximately 47% direct costs, 44% indirect
costs, 9% capital costs, and less than 1% each for nurse aid training and criminal records checks.72 The direct
costs include costs for direct care staff. DMAS rebases (i.e., recalculates) rates triennially using cost data; all
reimbursement rates are prospective, which means that providers are responsible for managing a resident’s cost
of care.
In discussions about what recommendations the work group would consider for voting upon, the work
group felt that data regarding what constitutes a regionalized living wage for direct care staff should be one of
the data sources that DMAS looked to when it rebased its rates. Similar to the above discussion, no strong
preference was expressed for United for ALICE or the MIT Living Wage Calculator, so both are included as
options below. The work group also discussed the frequency of rebasing the nursing home rates. The rates are
presently rebased every three years and a recommendation, if adopted by the General Assembly, on that same
time interval would be easier for DMAS to administer. However, the work group also recognized that cost of
living can be quite variable, especially with economic conditions like the Great Recession of 2008 and the
economic downturn associated with the COVID-19 pandemic; in light of this variability, the work group also
voted recommendations that would require rebasing to be annual.
The work group also discussed ways to incentivize nursing homes to both provide higher wages to direct
care staff and to encourage higher staffing levels, as the work group received several public comments including
comments from Erin Hines, a work group member, about the burnout and attrition of current direct care staff.
Staffing levels have been mandated in several other jurisdictions, either in the form of minimum resident-to-
staff ratios or in the form of minimum hours per resident day (HPRD) (Appendix I). While attempts have been
made in prior legislative sessions to mandate minimum staffing in nursing homes, those bills have been
71 See 12VAC30-90-44.
72 Criminal records checks are mandated by Va. Code § 32.1-126.01 for all compensated employees.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
unsuccessful in part because some stakeholders argue that there is insufficient clinical workforce for all nursing
homes to be able to hire enough staff to meet the proposed minimums and in part because nursing homes do
not receive high enough Medicaid reimbursement to offer competitive salaries. The work group voted on
several recommendations—some with specific suggested staffing minimums and others that leave the staffing
minimums to the discretion of the General Assembly—that were paired with a pay for performance program
through DMAS to provide additional reimbursement for nursing homes that could meet minimum staffing and
quality of care outcomes. In all cases, the recommendations that the work group voted on used a multi-biennial
progression to increase what the minimum staffing requirements are. DMAS previously had a pay for
performance program for certified nursing facilities in the early 2000s that was discontinued in part due to the
requirement that DMAS audit 100% of facilities.
It should be noted that these recommendations would only benefit those nursing homes that are both
licensed and certified.
No. Recommendation Voting Result
17 Rebase the Medicaid reimbursement rate annually based on regionalized living 8Y - 0N - 9A
wage standards (derived from United For ALICE project data aggregated
according to the local workforce board region) and mandating rate increases
are passed on to direct care workers by implementing a wage pass-through
program
18 Rebase the Medicaid reimbursement rate annually based on regionalized living 7Y - 0N - 10A
wage standards (derived from MIT Living Wage Calculator aggregated
according to the local workforce board region) and mandating rate increases
are passed on to direct care workers by implementing a wage pass-through
program
19 Rebase the Medicaid reimbursement rate triennially based on regionalized living 8Y - 0N - 9A
wage standards (derived from United For ALICE project data aggregated
according to the local workforce board region) and mandating rate increases
are passed on to direct care workers by implementing a wage pass-through
program
20 Rebase the Medicaid reimbursement rate triennially based on regionalized living 7Y - 0N - 10A
wage standards (derived from MIT Living Wage Calculator aggregated
according to the local workforce board region) and mandating rate increases
are passed on to direct care workers by implementing a wage pass-through
program
21 Pay for performance program through DMAS to provide additional 8Y - 2N - 7A
reimbursement to facilities meeting minimum resident-to-staff ratios and
meeting minimum quality of care standards as determined by DMAS, with such
threshold ratios for additional reimbursement increasing every biennium for
three biennia
22 Pay for performance program through DMAS to provide additional 7Y - 1N - 9A
reimbursement to facilities meeting minimum resident-to-staff ratios and
meeting minimum quality of care standards as determined by DMAS, with such
threshold ratios for additional reimbursement beginning at 12-to-1 and
increasing to 6-to-1 over for four biennia
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
23 Pay for performance program through DMAS to provide additional 7Y - 1N - 9A
reimbursement to facilities meeting minimum hours of nursing care per
resident, with such threshold hours for additional reimbursement increasing
every biennium for three biennia
24 Pay for performance program through DMAS to provide additional 6Y - 0N - 11A
reimbursement to facilities meeting minimum hours of nursing care per
resident and meeting minimum quality of care standards as determined by
DMAS, with such threshold hours for additional reimbursement beginning at
3.5 hours and increasing to 4.1 hours over for three biennia
WORKFORCE-RELATED RECOMMENDATIONS
The work group also looked to the wider workforce and what barriers might exist to their entry into either
the health professions, the nursing home clinical workforce, or both. As part of these discussions, the work
group heard from representatives of the Virginia Department of Veterans Services (DVS), the Virginia
Department for the Blind and Vision Impaired (DBVI), the Virginia Department for the Deaf and Hard of
Hearing (VDDHH) as to what they perceived as stumbling blocks to joining the nursing home clinical
workforce.
SUPPORTING PERSONS WITH DISABILITIES
Representatives from DBVI and VDDHH spoke at length about the barriers that persons with disabilities
face when seeking employment. They touched upon that though there are federal laws protecting persons with
disabilities and the need for employers to make reasonable accommodations, the mere act of getting hired can
be a barrier due to potential employers being uncertain about what accommodations would be needed and how
they would accomplish those accommodations. Contemporaneous to these presentations was DVS’s
presentation about the Virginia Values Veterans (V3) program. The V3 programs helps employers develop and
implement long-term strategies and nationally recognized best practices in recruiting, hiring, and retaining
veterans.73 The work group discussed and included as a recommendation to be voted upon that would create a
similar program for employers hiring persons with disabilities.
On the topic of accommodations and potential employer hesitance about hiring persons with disabilities,
DBVI and VDDHH representatives did discuss that there is the Disabled Access Credit, a federal income tax
credit for small businesses that incur expenditures for the purpose of providing access to persons with
disabilities.74 A similar tax credit is not currently available at the state-level and because of how the Internal
Revenue Service (IRS) defines “small business,”75 it is very unlikely that any nursing home in Virginia would
qualify for the credit; additionally, no not-for-profit nursing home would be eligible for an income tax credit
since they are exempt from federal income taxes under subsection 501(c) of the IRS tax code.76 The work group
discussed voting on a recommendation that included a state income tax credit for for-profit nursing homes that
would otherwise mirror the Disabled Access Credit and a similar program for not-for-profit nursing homes
structured as a partial offset for payroll taxes.
73 “Virginia Values Veterans (V3) Program.” Virginia Department of Veterans Services, 2021. https://dvsv3.com/.
74 “Tax Benefits for Businesses Who Have Employees with Disabilities.” U.S. Internal Revenue Services, 2021.
https://www.irs.gov/businesses/small-businesses-self-employed/tax-benefits-for-businesses-who-have-employees-with-
disabilities.
75 An eligible small business is one that earned $1 million or less or had no more than 30 full time employees in the
previous year. Ibid.
76 “Federal Tax Obligations of Non-Profit Corporations.” U.S. Internal Revenue Services, 2021.
https://www.irs.gov/charities-non-profits/federal-tax-obligations-of-non-profit-corporations.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
No. Recommendation Voting Result
25 Creating a workforce program similar to DVS’s V3 Program for people with 12Y - 1N - 4A
disabilities to increase employment opportunities and promote economic
development by training and certifying organizations in disability workforce
best practices
32 State income tax credit for for-profit nursing homes based on expenditures 6Y - 2N - 9A
aimed at providing access to employees with disabilities
33 Tax relief program for not-for-profit nursing homes that would allow them to 9Y - 2N - 6A
offset part of their payroll tax for expenditures aimed at providing access to
employees with disabilities
SUPPORTING VETERANS
DVS also presented to the work group about the Military Medics and Corpsmen (MMAC) Program, which
recruits, reviews, and refers veterans to healthcare employers statewide.77 Veterans provide the MMAC team
with their educational and career goals, which the MMAC team uses to help facilitate their transition to the
Virginia’s civilian healthcare workforce. The MMAC team matches veterans to partner healthcare employers78
in the region of Virginia requested by the veteran and utilizes a multi-pathway approach to account for a
veteran’s general scope of practice, how recently the veteran has engaged their general scope of practice, non-
clinical experience, and operational or management experience.
As part of this presentation, DVS representatives spoke to the barriers currently facing the MMAC. Since
state nursing home regulations may prohibit care for non-credentialed veterans participating in the MMAC
program, DVS suggested that the work group consider recommending that the nursing home regulations be
amended, which could require a statutory change. DVS representatives also pointed out that CMS does
recognize the civilian equivalency of certain military allied health specialties. While DHP does recognize
substantially equivalent military education and training of medical professionals as appropriate,79 the extent to
which the training/education is recognized or applied to requirements for licensure depends upon the
profession, the licensure qualifications, and the nature of the military education/training. DVS representatives
also noted that it faces challenges raising awareness, including in nursing homes, of the MMAC program and
other DVS employment programs. The work group considered these recommendations and voted on them, as
indicated below
No. Recommendation Voting Result
26 Require changes to nursing home regulations to permit care by non- 9Y - 3N - 5A
credentialed individuals in the MMAC program
27 Civilian credentialing/licensing reciprocity so state regulatory bodies recognize 11Y - 1N- 5A
civilian equivalency of certain military allied health specialties
28 Civilian educational credits for statewide standardized recognition of military 11Y - 1N- 5A
medical education and awarding of equivalent credit hours
77 “Military Medics and Corpsmen (MMAC) Program.” Virginia Department of Veterans Services, 2021.
https://www.dvs.virginia.gov/education-employment/military-medics-corpsmen-mmac-program.
78 These partners include major health systems in Virginia and Virginia state agencies.
79 See Va. Code § 54.1-118.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
29 Funding for awareness campaign for MMAC Program and the healthcare 11Y - 0N - 6A
employment opportunities provided by the program
OTHER RECOMMENDATIONS
In addition to the state tax incentives discussed above in the “Supporting Persons with Disabilities”
subsection, the work group further discussed the federal Work Opportunity Tax Credit (WOTC). The WOTC
is available to employers for hiring individuals from certain targeted groups who have consistently faced
significant barriers to employment.80 The target groups include:81
Temporary Assistance for Needy Families (TANF) recipient
Qualified veteran82
Qualified ex-felon83
Designated community resident84
Vocational rehabilitation referral
Summer youth employee
Supplemental Nutrition Assistance Program (SNAP) recipient
Supplemental Security Income recipient
Long-Term Family Assistance recipient
Qualified long-term unemployment recipient85
As part of the discussions surrounding how the recommendation should be written and voted upon, the
work group decided that the qualifying groups of disadvantaged persons should be left to the General
Assembly’s discretion.
The work group also discussed a state income tax credit for CNAs, LPNs, and RNs, who work at licensed
nursing homes and certified nursing facilities. As part of the licensure process, VDH OLC collects the federal
employer identification number (FEIN) on its nursing home applications; similarly, DHP collects health care
80 “Work Opportunity Tax Credit.” U.S. Internal Revenue Service, 2021. https://www.irs.gov/businesses/small-
businesses-self-employed/work-opportunity-tax-
credit#:~:text=The%20Work%20Opportunity%20Tax%20Credit,faced%20significant%20barriers%20to%20employme
nt.
81 Ibid.
82 A “qualified veteran” is a veteran who is (a) receiving assistance under the SNAP (food stamps) for at least 3 months
during the first 15 months of employment; (b) unemployed for a period totaling at least 4 weeks (whether or not
consecutive) but less than 6 months in the 1-year period ending on the hiring date; (c) unemployed for a period totaling at
least 6 months (whether or not consecutive) in the 1-year period ending on the hiring date; (d) disabled and entitled to
compensation for a service-connected disability hired not more than one year after being discharged or released from
active duty in the U.S. Armed Forces; or (e) disabled and entitled to compensation for a service-connected disability who
is unemployed for a period totaling at least six months (whether or not consecutive) in the one-year period ending on the
hiring date.
83 A “qualified ex-felon” is a person hired within a year of being (a) convicted of a felony or (b) released from prison from
the felony.
84 A “designated community resident” is a person who, on the date of hire, (a) is at least 18 years old and under 40, (b)
resides within an Empowerment zone, Enterprise community, or Renewal community, and © continues to reside at the
locations after employment.
85 A “qualified long-term unemployment recipient” is a person who has been unemployed for not less than 27 consecutive
weeks at the time of hiring and received unemployment compensation during some or all or the unemployment period.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
practitioners’ social security numbers. This information could be supplied to the Virginia Department of
Taxation to aid in validating information from taxpayers claiming this credit.
Dignity for the Aged86 presented information to the work group about feedback it received from 100 CNAs
regarding their self-reported reasons for considering leaving or actually leaving the clinical workforce. Out of
100 CNAs, 59% reported low wages, 51% reported burnout or understaffing, 41% reported physical issues,
33% reported lack of appreciation, and 15% reported co-worker issues (Appendix J). The work group discussed
a potential recommendation for the Joint Commission on Health Care to conduct a study on related nursing
home workforce matters, such as workplace culture and internal leadership development, to further address
retention and recruitment.
No. Recommendation Voting Result
30 State version of the federal work opportunity income tax credit for private- 6Y - 3N - 8A
sector businesses that hire individuals who have consistently faced significant
barriers to employment, as determined by the General Assembly
31 State income tax credit for CNAs, LPNs, and RNs working at licensed nursing 9Y - 1N - 7A
homes and certified nursing facilities
34 Direct Joint Commission on Health Care to conduct a study on direct care staff 11Y - 1N - 5A
recruitment and retention, workplace culture improvements, and internal
leadership development in nursing homes
86 Dignity for the Aged is an advocacy group founded to improve the lives of those in elder care facilities.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X A – C H A P T E R 9 3 2 OF T H E 2 0 2 0 A C T S OF A S S E M B LY
Availability of Clinical Workforce for Nursing Homes Study Mandate
Be it enacted by the General Assembly of Virginia:
1. § 1. That the Department of Health shall convene a work group to review and make recommendations
on increasing the availability of the clinical workforce for nursing homes in the Commonwealth. The work
group shall include representatives from the Virginia Health Care Association, the Virginia Center for Assisted
Living, Dignity for the Aged, the Virginia Nurses Association, LeadingAge Virginia, and other stakeholders as
appropriate. The Department shall collaborate with the Department of Health Professions, the Governor's
Chief Workforce Development Advisor, and other state agencies as appropriate. The Department shall report
all recommendations to the Chairmen of the Senate Committee on Education and Health and the House
Committee on Health, Welfare and Institutions on or before November 15, 2020.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X B – A C R ON Y M S A N D A B B R E V I A T I ON S
This is a listing of the acronyms and abbreviations appearing throughout the report and its appendices.
ALICE – asset limited, income constrained, employed
BRCC – Blue Ridge Community College
CMP – civil monetary penalty
CMS – U.S. Centers for Medicare and Medicaid Services
CNA – certified nurse aide
COP – condition of participation
CTE – career and technical education
DBVI – Virginia Department for the Blind and Vision Impaired
DHP – Virginia Department of Health Professions
DMAS – Virginia Department of Medical Assistance Services
DVS – Virginia Department of Veterans Services
FTE – full-time equivalent
HPRD – hour per resident day
HWDC – Healthcare Workforce Data Center in DHP
IRS – Internal Revenue Service
LPN – licensed practical nurse
LWDA – local workforce development area
MIT – Massachusetts Institute of Technology
MMAC – Military Medics and Corpsmen
OLC – Office of Licensure and Certification in VDH
PBJ – Payroll-Based Journal
RN – registered nurse
VBOE – Virginia Board of Education
VDDHH – Virginia Department for the Deaf and Hard of Hearing
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
VDH – Virginia Department of Health
V3 – Virginia Values Veterans
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X C – WO R K G R OU P M E E T I N G M I N U T E S
JULY 6, 1:00 P.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Judy Jackson, Karen Brimm, Eric Raff, Joani Latimer, Kathryn Paxton, Charlette Ridout,
Elizabeth Carter, Sam Kukich, Lionel DeCuir, Senator Jen A. Kiggans, Melissa Andrews, Alicia Cundiff,
Randall Stamper, W. Scott Johnson, Susan Hines, Erin Hines, Barbara Seymour.
VDH Staff Present: Joseph Hilbert, A. Carole Pratt, Rebekah Allen, Mylam Ly.
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. There were no speakers signed up.
Proposed Work Group Roadmap
Dr. Pratt, Senator Kiggans, and W. Scott Johnson provided an introduction and background for the Chapter
932 work group.
Dr. Elizabeth Carter provided an overview of the current nursing workforce in Virginia.
Melissa Andrews provided an overview of LeadingAge’s national initiatives to support nursing home
workforce recruitment and retention.
Representatives for Dignity for the Aged want the group to explore causes for workforce shortages
and whether or not requirements for staffing ratios will mitigate drivers of workforce shortages, such
as burnout.
Initial Discussions on Educational Pipeline
The work group reviewed the current pipeline for nurses providing care in Virginia’s nursing homes,
barriers to recruitment and retention, and additional training needs of Virginia nursing home staffing
workforce.
The work group discussed opportunities to partner with K-12 schools to educate students on the
opportunities to work in nursing homes as well as leveraging civic engagement requirements to provide
exposure to employment opportunities in nursing homes.
Discussion of Next Steps
Ms. Allen will be researching civic engagement requirements for Virginia’s K-12 schools.
VDH staff will begin researching nursing home staffing ratios in other states.
VDH will work with DHP to review CNA disciplinary data.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
VDH will work with VHCA to determine if there are any relevant data to explore as a result of CNA
exit surveys.
VDH will work with partners to understand if there are other data to determine why CNAs are leaving
nursing home settings.
VDH staff will research opportunities to include leadership development competencies in CNA
training programs.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 2:54 p.m.
The meeting recording is available at: https://youtu.be/_edjZDVqZ9c
JULY 20, 1:00 PM
This meeting was a hybrid with some members gathering at the Perimeter Center (9960 Mayland Drive,
Henrico, VA 23233) and others attending virtually.
Members Present: Alaysia Black Hackett, Megan Healy, Joani Latimer, Kathryn Paxton, Elizabeth Carter,
Corie Tillman Wolf, Todd Barnes, Sam Kukich, Bob Kukich, Erin Hines, Susan Hines, Senator Jen A. Kiggans,
Christina Holloway, Dana Parsons, Alicia Cundiff, W. Scott Johnson, Vivienne McDaniel, Barbara Seymour,
Lionel DeCuir.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah Allen
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There were 4 speakers signed up:
Kathy Schroeder stated that Virginia’s nursing home ranking of 36th nationwide is due to lack of
enforcement to facilities and the lack of support to CNAs.
Patricia Vannucchi stated that she has not been allowed to see her mother since the beginning of the
COVID-19 pandemic, and she fears that the lock down of the facility and staffing shortages are
exacerbating her mother’s illnesses.
Ms. Niak stated that her mother has lost weight and is pleading for help during virtual face to face
meetings and that the staff is struggling to keep up with the needs of residents.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Deborah Buchanan stated that the challenges faced by nursing homes are not specific to one facility
and that staffing ratios can be to blame. In addition, poor treatment of residents is causing poor
outcomes and premature death.
Review of Work Group Roadmap and Revisions
As a follow up to the work group’s first meeting, focus area for the work group will be educational pipelines,
training curriculum, student debt, payer mix, reimbursement rates, and financial incentive programs.
Key drivers of recruitment and retention are salary and wages, benefits, staffing ratios, advancement
opportunities, and leadership opportunities.
Initial Discussions regarding Curriculum and Educational Debt
Ms. Allen presented on Virginia’s K-12 service learning requirements as well as those in other states
across the nation.
Dr. Pratt presented on rural health workforce development programs in Virginia.
Ms. Allen presented on opportunities to support training programs of special needs populations.
Heather Anderson presented on Virginia’s State Loan Repayment Programs.
Discussion of Next Steps
Ms. Allen and Dr. Pratt will be working with DVS and DBVI to finalize curriculum recommendations
for special needs populations as well as programs to help veterans transition into the civilian workforce.
The group will prepare to discuss financial incentive programs for nursing home staffing recruitment
and retention.
A discussion of payer mix for nursing homes will be prepared.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 4:01 p.m.
The meeting recording is available at: https://youtu.be/MB08lSmuozU
AUGUST 4, 1:00 P.M.
Due to Executive Order 69 that declares a state of emergency due to Hurricane Isaias, this meeting was
conducted in an all-virtual environment.
Members Present: Judy Jackson, Karen Brimm, Joani Latimer, Kathryn Paxton, Charlette Ridout, Elizabeth
Carter, Corie Tillman Wolf, Todd Barnes, Bob Kukich, Erin Hines, Susan Hines, Tyler Edmonds, Christina
Holloway, Dana Parsons, Alicia Cundiff, W. Scott Johnson, Vivienne McDaniel, Randall Stamper, Meaghan
Green, Lionel DeCuir, Barbara Seymour.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah Allen
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
25
GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There were 2 speakers signed up. Both were unable to provide their statements due to technical
difficulties.
W. Scott Johnson spoke to remind the group that they are charged with finding workforce solutions
and that all have the same goal of finding mechanisms for supporting nursing home staff and nursing
home residents.
Suggestions for Health Care Curriculum and Career Pathways for Special Needs Populations
Karen Brimm and Judy Jackson presented on the need to train workforce who are deaf or hard of hearing and
those serving those that are deaf or hard of hearing, including cultural competency.
Suggestions for Transitions to Civilian Careers in Health Care and Nursing Homes
Todd Barnes presented on programs to help veterans transition to health care careers in nursing homes,
including leveraging the MMAC Program, Virginia Transition Assistance Program (VTAP), and V3 Program.
Initial Discussions on Health Care Financing - Payer Mix, Reimbursement Rates, and Financial
Incentive Programs
Ms. Allen presented on the payer mix for Virginia’s certified nursing facilities, full-time equivalents, labor costs,
revenues, profit margins, and reimbursement rates. Ms. Allen also presented on Virginia’s tax incentive
programs that nursing homes can further leverage to support staffing recruitment and retention, including the
Work Opportunity Tax Credit (WOTC) and Disabled Access Credit. Ms. Allen provided an overview of
Virginia’s nursing home Medicaid participation.
Discussion of Next Steps
Ms. Allen will be scheduling the next meeting to ensure there are no conflicts with the 2020 General
Assembly August Special Session.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 3:54 p.m.
The meeting recording is available at: https://youtu.be/uY33AkY401w
AUGUST 17, 1:00 P.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Meaghan Green, Judy Jackson, Joani Latimer, Charlette Ridout, Elizabeth Carter, Corie
Tillman Wolf, Kurt Elward, Barbara Seymour, Randall Stamper, Todd Barnes, Bob Kukich, Sam Kukich, Erin
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Hines, Susan Hines, Senator Jen A. Kiggans, Melissa Andrews, Alicia Cundiff, April Payne, W. Scott Johnson,
Vivienne McDaniel, Lionel DeCuir.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah E. Allen.
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There were 3 speakers signed up.
Erin Hines highlighted the perceived disconnect between long-term care facility administrators and
CNAs.
Sam Kukich implored the working group to focus on key drivers of nursing home staffing challenges,
including staffing ratios.
Susan Hines discussed the need to increase recruitment efforts and mandate staffing ratios for
Virginia’s nursing homes.
Lionel DeCuir spoke to the need to increase the amount of direct care provided to residents of long-
term care facilities in Virginia
Claude Moore Scholars
Dr. William A. Hazel Jr. M.D. provided an overview of the Claude Moore Scholars Healthcare Education
Program, which provides funds to public school systems and institutions of higher education to develop and
maintain Career and Technical Education (CTE) programs and is interested in partnering with Virginia
stakeholders to develop and expand healthcare workforce pipeline programs.
Medicaid Rate Setting and Sources of Virginia Medicaid Funding
Sonja Lee-Austin and Sara Benoit presented on nursing facility Medicaid reimbursement in Virginia, including
how rates are set and adjusted.
DMAS & Medicaid Incentive Programs
Terry Smith, Tim Catherman, and Evelyn Hardwick presented on DMAS’ various training and incentive
programs, including trauma-resilience training for CNAs, curriculum development for Advanced Certification
of CNAs, and peer mentoring programs.
Workforce Development Programs
Meaghan Green presented on nursing and other long-term care facility workforce trends as well as opportunities
to recruit the workforce impacted by the COVID-19 pandemic into high-need long-term care settings. Meaghan
Green also presented wage data, indicating that in many communities, CNAs make less than living wages in
Virginia and on Virginia’s career pathways and workforce development programs. Key takeaways from
reviewing trend data and lessons learned from the trend analysis are that pay increases, innovative benefit
incentives, and additional workforce supports are needed to improve nursing home staff recruitment and
retention.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Recruitment & Retention: Medicaid Funding, Recommendations for Workforce, and Pathways for
Implementation
Keith Hare provided an overview of the resident and staffing demographics representing the Virginia Health
Care Association’s membership as well as the payer mix for Virginia’s nursing home residents. Mr. Hare also
reviewed the financial and operational impacts of COVID-19 on Virginia’s nursing homes and potential
opportunities to address workforce gaps, including temporary nurse aide training programs, FastForward
Virginia, and scholarship programs.
Discussion of Next Steps
VDH will be preparing a presentation on staffing ratios in preparation for the next work group meeting.
VDH will work to distribute meeting minutes to work group members.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 3:35 p.m.
The meeting recording is available at: https://youtu.be/UyZBKwWcUwY
AUGUST 31, 1:00 P.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Judy Jackson, Karen Brimm, Charlette Ridout, Corie Tillman Wolf, Todd Barnes, Heather
Legere, Sam Kukich, Randall Stamper, Erin Hines, Susan Hines, Lionel DeCuir, Senator Jen A. Kiggans,
Melissa Andrews, Dana Parsons, Alicia Cundiff, April Payne, W. Scott Johnson, Vivienne McDaniel, Joani
Latimer, Steve Ankiel, Elizabeth Flaherty.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah E. Allen, Brenden Rivenbark
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Nursing Home Staffing and Supporting the Development of Virginia’s Nursing Home Workforce
Brenden Rivenbark provided an overview of research conducted that highlights strategies other states have
utilized in mandating staffing ratios in nursing homes. While not every state was analyzed, data comparing ratios
reported to CMS, hospitalizations per 1,000 long-stay resident days, CNA hourly mean wages, total CNA
workforce, employment per 1,000 jobs, and Medicaid expenditures per aged enrollees were produced for
California, Illinois, Maine, Florida, Virginia, the District of Columbia, and nationally.
Review of Recommendations Discussed to Date
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Ms. Allen reminded the work group of the Chapter 932 mandate set forth by the General Assembly and
highlighted potential recommendations provided by work group members to-date.
Discussion of Next Steps
Ms. Allen will continue to draft recommendations for the work group to discuss during the next
meeting.
Ms. Allen will work with DMAS to understand necessary budget language that would ensure that any
additional funding provided for nursing homes be allocated to direct staffing expenditures.
Other Business
There was no other business discussed.
Public Comment Period
Ms. Allen indicated that no speakers signed up for public comment.
Adjourn
Meeting adjourned at 3:54 p.m.
The meeting recording is available at: https://youtu.be/3dYpmDkwdjM
SEPTEMBER 25, 1:00 P.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Meaghan Green, Karen Brimm, Joani Latimer, Kathryn Paxton, Charlette Ridout,
Elizabeth Carter, Corie Tillman Wolf, Todd Barnes, Heather Legere, Lionel DeCuir, Tyler Edmonds, Christina
Holloway, Dana Parsons, April Payne, Vivienne McDaniel, Sam Kukich, W. Scott Johnson, Judy Jackson,
Barbara Seymour.
VDH Staff Present: A. Carole Pratt, Rebekah E. Allen.
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Roll Call
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There was 1 speaker signed up.
Sam Kukich stated that she was concerned about the prioritization of money over quality of care for
nursing home residents.
Review of Recommendations To Be Voted Upon
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Ms. Allen presented the 17 recommendations that have been produced by the work group to date for review,
revision, and voting. It was requested by the work group that revisions be made to the draft recommendations
and that another meeting be held within the next week to finalize recommendations. On the topic of wages,
the work group reviewed average CNA wages to that of the average cost of living as reported by the United
Way’s ALICE research.
Discussion of Next Steps
The work group will convene one more time to vote on recommendations prior to VDH’s drafting of
the Chapter 932 work group, which will be reviewed and voted upon in November.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 2:37 p.m.
The meeting recording is available at: https://youtu.be/FOjuJfKvM9U
SEPTEMBER 30, 1:00 P.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Judy Jackson, Karen Brimm, Kathryn Paxton, Charlette Ridout, Elizabeth Carter, Corie
Tillman Wolf, Sam Kukich, Erin Hines, Susan Hines, Lionel DeCuir, Dana Parsons, Alicia Cundiff, April Payne,
Vivienne McDaniel, Barbara Seymour.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah E. Allen.
Call to Order
Dr. Pratt called the meeting to order at 1:05 p.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There were 3 speakers signed up.
Ms. Kukich voiced her concerns that there were no meeting minutes provided and felt there was a lack
of transparency due to the lack of communication in meeting cancellations and lack of sharing of group
members’ contact information. Additionally, there was a concern that work group members’
recommendations or opinions were being ignored.
Erin Hines feels that the topic of supporting the current CNA workforce has been purposefully ignored
during the work group process.
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Susan Hines voiced concern that the work group has failed to address the quality concerns being
reported in many of Virginia’s nursing homes.
Review of Recommendations To Be Voted Upon
Ms. Allen provided an overview of the voting rules for the recommendations to be put forth by the work group.
Additionally, each of the 32 potential recommendations produced by the work group were put forward for final
review and revision.
Discussion of Next Steps for Work Group Report
Work group members will be sent a final copy of recommendations by October 2nd and a link for a
Google Form ballot by October 9th.
Votes on recommendations are due for submission by 11:59 p.m. October 19th.
The draft Chapter 932 work group report will be distributed to members by November 2nd.
The final meeting of the work group will be held on November 9th to discuss the draft Chapter 932
work group report.
The final draft of the Chapter 932 work group report will be sent to work group members and VDH’s
Deputy Commissioner for Governmental and Regulatory Affairs for filing.
Other Business
There was no other business discussed.
Adjourn
Meeting adjourned at 4:07 p.m.
The meeting recording is available at: https://youtu.be/BbBvseLf1QU
NOVEMBER 9, 9:00 A.M.
Due to COVID-19, this meeting was conducted in an all-virtual environment.
Members Present: Joani Latimer, Kathryn Paxton, Charlette Ridout, Corie Tillman Wolf, Barbara Seymour,
Sam Kukich, Senator Jen A. Kiggans, Alicia Cundiff, W. Scott Johnson, Vivienne McDaniel, Lionel DeCuir.
VDH Staff Present: Heather Anderson, A. Carole Pratt, Rebekah E. Allen, Brenden Rivenbark.
Call to Order
Dr. Pratt called the meeting to order at 9:03 a.m.
Introductions
Ms. Allen welcomed those in attendance to the meeting. Ms. Allen then started the introductions of the work
group members and VDH staff present.
Review of Agenda
Ms. Allen reviewed the agenda.
Public Comment Period
Ms. Allen opened the meeting for the Public Comment Period. Written comments were submitted to Ms. Allen
and Dr. Pratt. There was one speaker signed up.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Ms. Kukich expressed her concern that the work group focused on workforce development needs
rather than those of the current nursing home workforce.
Feedback on “Preface” and “Introduction”
No feedback was given.
Feedback on “VA Clinical Workforce for Nursing Homes”
No feedback was given.
Ms. Allen provided an overview of Report acronym definitions.
Feedback on “Education-Related Recommendations”
No feedback was given.
Feedback on “Wage-Related Recommendations”
No feedback was given.
Feedback on “Workforce-Related Recommendations”
No feedback was given.
Feedback on “Appendices”
Meeting minutes will be updated based on feedback.
Minutes should have reflected real time feedback.
A more concise report may be most effective.
National nursing home rating reports would be valuable points of reference.
Other Business
Dr. Pratt thanked work group members for effort, time, and contributions to work group efforts.
Senator Kiggans thanked work group members for effort, time, and contributions to work group
efforts.
Final report feedback is due by the end of November 11, 2020.
The feedback template will be resent to the work group.
Adjourn
Meeting adjourned at 9:58 a.m.
The meeting recording is available at: https://youtu.be/eA8OvY-3AH8
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A P P E N D I X D – S U M M A RY OF W R I T T E N C OM M E N T S F ROM T H E P U B L I C
JULY 6 MEETING
No written comments were received.
JULY 20 MEETING
Brenna Behel
Ms. Behel requested that Virginia establish minimum staffing ratios for nursing homes.
Deborah Buchanan
Ms. Buchanan requested that the work group focus on staffing ratios, adhere to the requirements set forth in
the Omnibus Budget Reconciliation Act of 1987, and sufficient and effective regulation and enforcement of
facilities.
Elizabeth Caine
Ms. Caine requested that Virginia establish minimum staffing ratios for nursing homes.
Eleanor Charnock
Ms. Charnock requested that the work group address the poor quality of care in nursing homes as a result of
insufficient staffing.
Lionel DeCuir
Mr. DeCuir implored the work group to hold regulators of nursing homes accountable for poor outcomes
experienced by nursing home residents and information for sites that rank nursing homes based on quality.
Marc Fortunato
Mr. Fortunato expressed his concern that insufficient staffing in nursing homes has led to the poor quality of
care received by a loved one in a Virginia facility.
Kathy Schroeder
Ms. Schroeder shared her concerns that long-term care administrators have too much power with little
accountability and that staff interacting directly with residents have few supports to do their job adequately.
Patricia Vannucchi
Ms. Vannucchi wished to know how it was possible that facilities could still be so short staffed when they were
provided an enhanced Medicaid benefit during the pandemic. Ms. Vannucchi also expressed her concern with
the perceived lack of proper infection control and compassionate care practiced by nursing home staff.
AUGUST 4 MEETING
Lynn McNelis
Ms. McNelis requested that the work group mandate nursing home staff to resident ratios.
Cindy Bocrie
Ms. Bocrie shared her experiences as a nurse and working in a nursing home to request that Virginia support
the expansion of a companion work force in nursing homes to support CNAs with resident activities of daily
living.
Michele Reed
Ms. Reed requested that Virginia establish minimum staffing ratios for nursing homes.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Laura Duval
Ms. Duval requested that Virginia require basic parameters such as socialization, the number of CNAs, and
better wages to enhance quality in nursing homes.
Janet Slavett
Ms. Slavett requested that the work group mandate nursing home staff to resident ratios.
Kathy Schroeder
Ms. Schroeder voiced her frustration that the work group was focusing on nursing home staffing pipelines
rather than challenges facing nursing homes today.
Marc Fortunato
Mr. Fortunato voiced his frustration that the work group was focusing on nursing home staffing pipelines
rather than challenges facing nursing homes today.
Cheryl Waldrup
Ms. Waldrup requested that the work group mandate nursing home staff to resident ratios.
Linda Talbot
Ms. Talbot, a former CNA, requested that Virginia increase wages for CNAs.
Laura Ortiz
Ms. Ortiz requested that the work group mandate nursing home staff to resident ratios.
Deborah Buchanan
Ms. Buchanan requested that Virginia increase the number of CNAs working in Virginia to increase the quality
of care.
Joani Latimer
Ms. Latimer expressed concern that the work group’s extensive focus so far on pipeline/recruitment issues may
limit getting to the real root of the workforce shortages, retention and recruitment. These factors include low
wages, morale, understaffing, and workplace culture.
AUGUST 17 MEETING
Charlette Ridout
Ms. Ridout shared a positive story of her father’s experience in his nursing home in Richmond. She also shared
information pertaining to the suspension of 18VAC90-26-20(B)(1)(e) until December 31, 2020.
Keith Hare
Mr. Hare explained that the historic nursing home staffing challenges are multifaceted and that establishing
staffing mandates do not address the complex educational and cultural layers that drive staffing shortages.
Sam Kukich
Ms. Kukich shared perspectives of CNAs she has spoken with about barriers to recruitment and retention,
which include pay, burnout, cost of education, benefits, lack of ratios, lack of integration with the care team,
lack of training by the facility, and poor communication from leadership.
Lionel DeCuir
Mr. DeCuir shared links to sites that rank nursing homes based on quality of care, including CMS. Mr. DeCuir
also requested that the work group focus on mandatory staffing ratios in nursing homes.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Erin Hines
Ms. Hines shared the results of a survey she conducted with CNA colleagues, which indicated that many of the
respondents felt that facility leadership did not meaningfully engage staff.
AUGUST 31 MEETING
W. Scott Johnson
Mr. Johnson shared national survey data reporting financial hardships faced by nursing homes due to COVID-
19.
Sam Kukich
Ms. Kukich shared research she conducted indicating that poor nursing home quality can be attributed to
private equity ownership of nursing homes.
Erin Hines
Ms. Hines shared the results of a survey she conducted with CNA colleagues, which indicated that many of the
respondents felt that CNAs leave the industry because of low pay, burnout, cost of education, benefits, lack of
ratios, lack of integration with the care team, lack of training by the facility, and poor communication from
leadership.
Susan Hines
Ms. Hines requested that the work group mandate nursing home staff to resident ratios.
SEPTEMBER 25 MEETING
Sam Kukich
Ms. Kukich shared information from a CNA who had contacted her regarding the justification for no longer
serving as a CNA, which was attributed to high burnout as a result of low staffing supports and high demands.
Ms. Kukich also shared the story of her mother’s experience in a nursing home, of which she attributed quality
challenges to poor staffing ratios and tools for success. It was also noted that meeting minutes had not yet been
provided to the work group and that more communication would be valuable to the mission of the work group.
SEPTEMBER 30 MEETING
Sam Kukich
Ms. Kukich reiterated her desire for the work group to focus on nursing home staffing ratios rather than other
solutions to support the future workforce and mentioned that numerous private citizens had contacted her to
express their concerns about quality of care in nursing homes. Ms. Kukich also provided service learning
guidance from the Virginia Department of Education.
NOVEMBER 9 MEETING
Kathy Schroeder
Ms. Schroeder voiced her concern about the lack of materials provided prior to the Work Group meetings and
displeasure that the drafted recommendations serve as a reward system for facilities that provide low quality
care rather than requirements to increase the quality of care.
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A P P E N D I X E – S TA K E H O L D E R VOT I N G R E C OR D O N WO R K G ROU P R E C OM M E N DA T I ON S
1. Permit, but not require, local school boards to offer graduation credit for service learning in clinical
care in long term care settings. Service learning is an instructional strategy that combines meaningful
hands-on service to and for the benefit of the community with curriculum-based learning meeting
specified objectives defined by the local school board in consultation with DHP and VDH
a. Support: 11
b. Oppose: 1
c. Abstain: 5
2. Statewide offering of optional graduation credit for service learning in clinical care in long term care
settings. Service learning is an instructional strategy that combines meaningful hands-on service to and
for the benefit of the community with curriculum-based learning meeting specified objectives defined
by the VBOE in consultation with the DHP and VDH
a. Support: 11
b. Oppose: 1
c. Abstain: 5
3. Statewide offering of optional Fairfax County Public Schools model of hours-based service learning
(i.e., required for students in grades 6, 8, and 12, with optional diploma seal if additional hours are
completed) in clinical care in long term care settings. Service learning is an instructional strategy that
combines meaningful hands-on service to and for the benefit of the community with curriculum-based
learning meeting specified objectives defined by the VBOE in consultation with the DHP and VDH
a. Support: 9
b. Oppose: 1
c. Abstain: 7
4. Require changes to nursing home regulations to permit volunteerism in nursing homes, with
supervision that includes orientation and training for volunteers consistent with the tasks assigned,
recording the type of tasks and time worked, and method by which a volunteer may contact supervisor
for immediate assistance
a. Support: 10
b. Oppose: 2
c. Abstain: 5
5. Require changes to nursing home regulations to permit service learning in nursing homes, with
supervision that includes that includes orientation and training consistent with the tasks assigned,
recording the type of tasks and time worked, and method by which a learner may contact supervisor
for immediate assistance
a. Support: 12
b. Oppose: 1
c. Abstain: 4
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
6. Establish education and outreach programs for middle school and high school students to promote
career pathways in long term care
a. Support: 12
b. Oppose: 1
c. Abstain: 4
7. Funding for tuition of the Advanced Certification for CNAs upon conclusion of pilot program
a. Support: 10
b. Oppose: 1
c. Abstain: 6
8. Expand eligibility of Nurse Loan Repayment Program in Va. Code § 32.1-122.6:04 (also known as the
Mary Marshall Nursing Scholarship) to include CNAs
a. Support: 12
b. Oppose: 1
c. Abstain: 4
9. Fund the Nursing Scholarship and Loan Repayment Fund in Va. Code § 54.1-3011.2
a. Support: 11
b. Oppose: 1
c. Abstain: 5
10. Establish financial relief program to support direct care nursing home employees by covering a
percentage of childcare or dependent care costs
a. Support: 9
b. Oppose: 1
c. Abstain: 7
11. Establish financial relief program to support direct care nursing home employees by covering a
percentage of transportation costs to include public transportation costs
a. Support: 9
b. Oppose: 1
c. Abstain: 7
12. Establish financial relief program to support direct care nursing home employees by covering a
percentage of living costs, which may include housing, transportation, childcare or dependent care,
utilities, or other categories of expenses as determined by the General Assembly
a. Support: 7
b. Oppose: 2
c. Abstain: 8
13. Increase wages for CNAs proportional to regional living wage standards, with living wage standards
derived from United For ALICE project data aggregated according to the local workforce board region
a. Support: 9
b. Oppose: 1
c. Abstain: 7
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
14. Increase wages for CNAs proportional to regional living wage standards, with living wage standards
derived from Massachusetts Institute of Technology Living Wage Calculator aggregated according to
the local workforce board region
a. Support: 7
b. Oppose: 0
c. Abstain: 10
15. Increase minimum wage proportional to regional living wage standards, with living wage standards
derived from United For ALICE project data aggregated according to the local workforce board region
a. Support: 7
b. Oppose: 1
c. Abstain: 9
16. Increase minimum wage proportional to regional living wage standards, with living wage standards
derived from Massachusetts Institute of Technology Living Wage Calculator aggregated according to
the local workforce board region
a. Support: 5
b. Oppose: 0
c. Abstain: 12
17. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived
from United For ALICE project data aggregated according to the local workforce board region) and
mandating rate increases are passed on to direct care workers by implementing a wage pass-through
program
a. Support: 8
b. Oppose: 0
c. Abstain: 9
18. Rebase the Medicaid reimbursement rate annually based on regionalized living wage standards (derived
from Massachusetts Institute of Technology Living Wage Calculator aggregated according to the local
workforce board region) and mandating rate increases are passed on to direct care workers by
implementing a wage pass-through program
a. Support: 7
b. Oppose: 0
c. Abstain: 10
19. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards
(derived from United For ALICE project data aggregated according to the local workforce board
region) and mandating rate increases are passed on to direct care workers by implementing a wage
pass-through program
a. Support: 8
b. Oppose: 0
c. Abstain: 9
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
20. Rebase the Medicaid reimbursement rate triennially based on regionalized living wage standards
(derived from Massachusetts Institute of Technology Living Wage Calculator aggregated according to
the local workforce board region) and mandating rate increases are passed on to direct care workers
by implementing a wage pass-through program
a. Support: 7
b. Oppose: 0
c. Abstain: 10
21. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum staff-to-resident ratios and meeting minimum quality of care standards as
determined by DMAS, with such threshold ratios for additional reimbursement increasing every
biennium for three biennia
a. Support: 8
b. Oppose: 2
c. Abstain: 7
22. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum staff-to-resident ratios and meeting minimum quality of care standards as
determined by DMAS, with such threshold ratios for additional reimbursement beginning at 12-to-1
and increasing to 6-to-1 over for four biennia
a. Support: 7
b. Oppose: 1
c. Abstain: 9
23. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum hours of nursing care per resident, with such threshold hours for additional
reimbursement increasing every biennium for three biennia
a. Support: 7
b. Oppose: 1
c. Abstain: 9
24. Pay for performance program through DMAS to provide additional reimbursement to facilities
meeting minimum hours of nursing care per resident and meeting minimum quality of care standards
as determined by DMAS, with such threshold hours for additional reimbursement beginning at 3.5
hours and increasing to 4.1 hours over for three biennia
a. Support: 6
b. Oppose: 0
c. Abstain: 11
25. Creating a workforce program similar to Virginia Values Veterans (V3) Program for people with
disabilities to increase employment opportunities and promote economic development by training and
certifying organizations in disability workforce best practices
a. Support: 12
b. Oppose: 1
c. Abstain: 4
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
26. Require changes to nursing home regulations to permit care by non-credentialed individuals in the
MMAC program
a. Support: 9
b. Oppose: 3
c. Abstain: 5
27. Civilian credentialing/licensing reciprocity so state regulatory bodies recognize civilian equivalency of
certain military allied health specialties
a. Support: 11
b. Oppose: 1
c. Abstain: 5
28. Civilian educational credits for statewide standardized recognition of military medical education and
awarding of equivalent credit hours
a. Support: 11
b. Oppose: 1
c. Abstain: 5
29. Funding for awareness campaign for MMAC Program and the healthcare employment opportunities
provided by the program
a. Support: 11
b. Oppose: 0
c. Abstain: 6
30. State version of the federal work opportunity income tax credit for private-sector businesses that hire
individuals who have consistently faced significant barriers to employment, as determined by the
General Assembly
a. Support: 6
b. Oppose: 3
c. Abstain: 8
31. State income tax credit for CNAs, LPNs, and RNs working at licensed nursing homes and certified
nursing facilities
a. Support: 9
b. Oppose: 1
c. Abstain: 7
32. State income tax credit for for-profit nursing homes based on expenditures aimed at providing access
to employees with disabilities
a. Support: 6
b. Oppose: 2
c. Abstain: 9
33. Tax relief program for not-for-profit nursing homes that would allow them to offset part of their
payroll tax for expenditures aimed at providing access to employees with disabilities
a. Support: 9
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
b. Oppose: 2
c. Abstain: 6
34. Direct Joint Commission on Health Care to conduct a study on direct care staff recruitment and
retention, workplace culture improvements, and internal leadership development in nursing homes
a. Support: 11
b. Oppose: 1
c. Abstain: 5
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X F – S TA K E H O L D E R E X P L A NA T I O N S OF O P P OS I T I ON T O S P E C I F I C
R E C OM M E N DA T I ON S
RECOMMENDATION #1
Dignity for the Aged
The time, effort and cost associated with setting up this program is not worth the effort or guarantee an
increase of the clinical workforce, never mind benefit the elderly who are currently dying. Family members
currently are not allowed to help their own relatives due to restrictions in nursing homes. The service learning
would require staff to supervise, and most nursing homes are already understaffed.
RECOMMENDATION #2
Dignity for the Aged
The time, effort and cost associated with setting up this program is not worth the effort or guarantee an
increase of the clinical workforce, never mind benefit the elderly who are currently dying Family members
currently are not allowed to help their own relatives due to restrictions in nursing homes. The service learning
would require staff to supervise, and most nursing homes are already understaffed. The is no guarantee of
Return on Investment – the pay is so low, and the environment so unprofessional and stressful, it would not
take these kids much time to know that this field is not one they would want to obtain employment,
RECOMMENDATION #3
Dignity for the Aged
The time, effort and cost associated with setting up this program is not worth the effort and would not
benefit the elderly who are currently dying. Family members currently are not allowed to help their own relatives
due to restrictions in nursing homes. The service learning would require staff to supervise, and most nursing
homes are already understaffed. The is no guarantee of Return on Investment – the pay is so low, and the
environment so unprofessional and stressful, it would not take these kids much time to know that this field is
not one they would want to obtain employment,
RECOMMENDATION #4
Dignity for the Aged
The nursing home regulations are not currently even enforced!!! Resident Rights, BASIC Standards for
Care are ignored, why in the world would we change regulations that protect the elderly, when they are not
getting the care that they are paying for now?
Virginia Department for the Blind and Vision Impaired
DBVI supports the concept of regulating the use of volunteers in long term care facilities, however, it does
not support a requirement for the use of volunteers.
RECOMMENDATION #5
Dignity for the Aged
The nursing home regulations are not currently even enforced!!! Resident Rights, BASIC Standards for
Care are ignored. The Nursing Home IS FOR THE RESIDENT – do not hire anyone who is not qualified!!
RECOMMENDATION #6
Dignity for the Aged
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
There are plenty of programs available to promote career pathways in long term care, we do not need
children to start filling the vacancies that adults should be applying for, especially when we do not pay qualified
adults a decent wage. It would not take very many visits to a nursing home to find out that the job is thankless
and even more so when they can be paid more at a Fast Food restaurant with less stress.
RECOMMENDATION #7
Dignity for the Aged
As was discussed in our meetings, this pilot program would only include a very small percentage of CNAs.
Some of the discussion also conveyed that many Nursing Homes would not want to pay an increase salary for
Advanced Certification for CNAs, so the program would set CNAs up for expectations and pay that would not
be made available to them in the workplace. Why offer a pilot program?
RECOMMENDATION #8
Dignity for the Aged
Most CNA training programs are not expensive and in some cases are paid for by organizations if applicant
[sic] agrees to work at their facility.
RECOMMENDATION #9
Dignity for the Aged
The workforce area that needs to be focused on is the CNAs. THEY carry the load, THEY are
understaffed, THEY are not paid a wage that can support them, emphasis MUST be on increasing their pay
for daily life and increasing staff to prevent burn out - which would help increase the workforce.
RECOMMENDATION #10
Dignity for the Aged
The very fact that a “Financial Relief Program” is recommended is a clear message that the CNAs need an
increase in their salary. Why should they have to grovel and ask for financial relief, why not give them the
dignity they deserve and pay them a decent wage?????
RECOMMENDATION #11
Dignity for the Aged
If a CNA cannot provide for their own transportation to work, it seems obvious that their wages need to
be increased. It is not like they are taking an airplane to work. So why not increase their pay so they can provide
for themselves, why must they make so little that they need to beg for money to get to work? The very fact that
a “Financial Relief Program” is recommended is a clear message that the CNAs need an increase in their salary.
Why should they have to grovel and ask for financial relief, why not give them the dignity they deserve and pay
them a decent wage?????
RECOMMENDATION #12
Dignity for the Aged
Just pay them a respectable wage so they can pay for their own living costs, how would you feel if you had
to beg? No wonder the workforce is dwindling, it is obvious. More programs don’t support them, better wages
do! Could you live on $24,000 a year or less?
RECOMMENDATION #21
Virginia Department for the Blind and Vision Impaired
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
DBVI does not support this recommendation due to the mandate additional payments based on
minimums, not the optimum performance.
Virginia Health Care Association | Virginia Center for Assisted Living
Oppose staff-to-resident ratios
RECOMMENDATION #22
Virginia Health Care Association | Virginia Center for Assisted Living
Oppose staff-to-resident ratios
RECOMMENDATION #23
Office of the State Long-Term Care Ombudsman
While we support a Pay for Performance model to incentivize facilities to improve the level of staffing, we
believe that the criteria should include not only meeting the staffing threshold, but also meeting basic quality
of care [sic] standards at the same time.
RECOMMENDATION #25
Dignity for the Aged
The issue with caring for the elderly requires competent professionals. People with disabilities can be
helpful, however in a long term facility or nursing home, liability could be a risk that result in harm or death to
a resident.
RECOMMENDATION #26
Dignity for the Aged
Enforce the Nursing Home regulations!!! Residents are abused, neglected and dying due to no enforcement
of the regulations, too many slip through the cracks and are not provided proper care.
Virginia Department of Medical Assistance Services
Not clear as to meaning of "non-credentialed", question if speaking about military members that have no
healthcare background or experience. This would be a concern.
Virginia Nurses Association
Virginia law mandates that nurse aides complete 120 hours of training and that the training be provided by
a nurse aide school approved by the Virginia Board of Nursing. To work as a nurse aide in a nursing home an
individual must be certified, except for the time allotted a new graduate of a nurse aide education program prior
to completing the National Nurse Aide Assessment Program
(https://www.aeseducation.com/healthcenter21/what-is-the-nnaap-ex am-how-do-you-prepare-students-for-
it). A veteran in the MMAC program will not meet the requirements to become a certified nurse aide in the
state of Virginia which falls under certification by examination or certification by endorsement. Please see
18VAC90-25-71 Certification by examination and 18VAC90-25-72 Certification by endorsement found in the
Virginia Board of Nursing Regulations Governing Certified Nurse Aides
(https://www.dhp.virginia.gov/media/dhpweb/docs/nursing/leg/CNA020620.pdf)
After reading the qualifications for the MMAC program shown below, it does not appear that a veteran
would qualify by certification by examination or certification by endorsement nor would it benefit a long-term
care facility, if the individual requires constant monitoring by an already short of staff facility:
Pathway One – MMAC – Qualified: If you are a recently discharged Combat Medic/68W, Corpsman or
Medical Technician/4N0X with less than 12 months since last practicing hands-on clinical care you may be
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
MMAC-Qualified. MMAC has Memos of Agreement (MOA) with 10 major healthcare systems in Virginia. The
MMAC Partner Healthcare Systems (PHS) MOA allow MMAC-Qualified applicants to continue to practice
clinical procedures under supervision while gaining the education and credentialing required in civilian
healthcare. Only Virginia offers this option.
Additionally, there are no geriatric residents in the military that would allow a veteran to obtain the required
experiences. While these individuals may be skilled in recognizing sudden changes in the status of a geriatric
patient's condition, they may not be skilled in providing the type of care geriatric residents require on a daily
basis.
RECOMMENDATION #27
Dignity for the Aged
Everyone should have the same standards PERIOD
RECOMMENDATION #28
Dignity for the Aged
Everyone should have the same standards period. Working with seniors is much different than military
medical education and takes away from key qualifications.
RECOMMENDATION #30
Dignity for the Aged
Absolutely NOT. There are enough problems with theft, abuse and neglect, people need to fill the position
because they have the proper skill set and compassion necessary to care for the elderly!
RECOMMENDATION #31
Dignity for the Aged
As discussed in several meetings, increase their pay where they need it, a tax credit does nothing for day to
day living
RECOMMENDATION #32
Dignity for the Aged
We need qualified individuals working in Nursing Home facilities – the job involves physical fitness, mental
and educationally sound individuals. As per discussions, A [sic] deaf or blind person would not be capable of
helping elderly individuals in this line of work.
RECOMMENDATION #33
Dignity for the Aged
We need qualified individuals working in Nursing Home facilities – the job involves physical fitness, mental
and educationally sound individuals. As per discussions, A [sic] deaf or blind person would not be capable of
helping elderly individuals in this line of work
RECOMMENDATION #34
Dignity for the Aged
We have enough information from studies to fill a library the size of the Pentagon. We do not need to
waste one more dime on a study. In a nutshell, CNAs are leaving the field. They are not treated like
professionals, they don’t make enough money to provide for their basic needs, they are taking care of 20, 30 or
more patients which is impossible, they are overwhelmed, stressed out, burned out and no one cares enough
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
to pass a bill to establish ratios so they can do the job they were hired to do, which is care for the elderly in a
way that provides some dignity to the elderly and the workers. Get it together and pass a bill to mandate ratios
of 1 CNA to 6 residents! Think of your parents, friends or even yourself residing in a nursing home with no
one to answer your call button, sitting in your own waste for hours. We have all the data we need, if you need
more, please contact me at: skukich2002@yahoo.com.
Virginia Health Care Association | Virginia Center for Assisted Living
Oppose any JCHC study as that basically is another study of this study that VDH just did.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X G – S TA K E H O L D E R C OM M E N T S O N WO R K G R O U P D R A F T R E P ORT
Stakeholders were offered the opportunity to provide feedback and suggestions on the draft work group
report.
DIGNITY FOR THE AGED
https://nursinghomesabuseadvocate.com/WATCHLIST/
Above is the link for the Nursing Home Watch List that Lionel De Curr [sic] provided several times to the
panel. I have attached a document with a listing of the 50 homes87 that are on the Nursing Home Watch List
from Virginia. I included one of the Nursing Homes as an example88 to include in the Work Group Report as
requested in today's meeting. The Watch list document with the 3 supporting documents should be included
in the Appendices as Appendice [sic] I. Nursing Home Watch List.
As requested during today's meeting, please add this document89 as another Appendices. The link will
provide a well defined quick look at the specifics. I have also attached a document to include in the report that
would allow members of the GA a quick explanation for reference.
Virginia Details [https://www.familiesforbettercare.com/index.php/report-cards/details/va]
The following documents90 should be inserted into the report under Virginia's Clinical Workforce For
Nursing Homes under the subtitle of State of Workforce. This information directed much of the conversation
and was presented by Erin Hines concerning the shortages of CNAs. Including this information will provide a
much more accurate picture of why there are shortages in the workforce.
I believe in adding this information91 with a paragraph concerning panel discussion and public comments
you already recieved [sic], should be included in the report under the title of CMS Five Star Ratings for
Workforce as it will give more meaning to fact that Virginias [sic] ranking is quite low (36th) place as well as
having a grade of D due to understaffing - if further information is needed, they may access the Appendice [sic]
I previously send [sic] to be included.
I would recommend that this graphic92 which was discussed at length in meetings, be inserted under the
CMS Five Star Ratings for Workforce - under staffing - for the General Assembly to view actual data to address
the application of how staffing affects care. A note for further investigation can be included in the paragraph
to refer them to the Appendice [sic] for further information if needed. Including this will provide real life content
for insight and perspective.
87 Dignity for the Aged provided screenshots of the first 50 results from this webpage
https://nursinghomesabuseadvocate.com/watchlist/?ws=Hampton%2C+VA&distance=100&sortby= and a screenshot
of the webpage https://nursinghomesabuseadvocate.com/nursing-homes/coliseum-convalescent-and-rehabilitation-
center/.
88 Dignity for the Aged provided multiple screenshots of the webpage https://nursinghomesabuseadvocate.com/nursing-
homes/newport-news-nursing-rehab/.
89 Dignity for the Aged provided a screenshot of the webpage https://www.familiesforbettercare.com/index.php/report-
cards/details/va.
90 Dignity for the Aged provided materials that are reproduced in Appendix J.
91 Dignity for the Aged provide a screenshot of the webpage https://www.familiesforbettercare.com/index.php/report-
cards/details/va.
92 Dignity for the Aged provided a screenshot of the webpage https://nursinghomesabuseadvocate.com/nursing-
homes/newport-news-nursing-rehab/.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
OFFICE OF THE CHIEF WORKFORCE ADVISOR
The Office of the Chief Workforce Advisor provided 20 technical changes to address typographical errors,
sentence structure, and clarification of information and materials presented by Meaghan Green.
OFFICE OF THE STATE LONG-TERM CARE OMBUDSMAN
For Join [sic] Latimer’s affiliation, it is correct except for agency name, which should read Va. Department
for Aging and Rehabilitative Services
Remove Gail Thompson from the list, as she indicate [sic] she was an initial point of contact only, and did
not participate in the work group.
Financial Relief Programs
Regarding Recommendations # 10, 11, and 12
While our program does not specifically oppose these recommendations in that we would not wish to
thwart any measure that provides meaningful support/financial relief for our direct care staff, we have some
reservations about Recommendations 10 – 12 as the mechanism for that relief. In some ways, recommendations
10 -12 offer only partial relief at best and may actually become the stopgap measure that prevents our getting
to one of the primary roots of the problem – the lack of a true living wage and appropriate benefits for our
direct care staff.
Putting into place the kind of partial ‘propping up’ embodied by # 10-12 may actually defer and ultimately
undermine the potential for a solution that substantively addresses the problem. To pay our CNAs rock-bottom
wages while ‘propping up’ their situation with some relief ‘around the edges’ could be a detrimental and
dangerous policy. Rather than paternalistically offering ‘benevolences’ in a sense, we need to fairly compensate
our workforce, respecting and supporting their management of their living costs once they actually can make a
living.
Supporting Persons with Disabilities
While it may not be appropriate for inclusion in the report, I do wish to register a general concern with the
recommendations in this category. I would assume that all of the work group members would be supportive of
measures that eliminate barriers for persons with disabilities to meaningful employment. I believe that our
disabled citizens represent an insufficiently tapped national treasure that might well positively infuse our
struggling long-term care workforce. Eliminating such barriers for these individuals is a moral imperative and
an important public policy goal. At the same time, unless policies of this sort are enacted in concert with
significant improvements in the quality of long-term care workforce jobs, we may do harm to our disabled
citizens, essentially ‘throwing them into the fire.’
C. Summary of Written Comments from the Public
I think the following better captures the thrust of my written comments (Aug 4):
Joani Latimer expressed concern that the work group’s extensive focus so far on pipeline/recruitment
issues may limit getting to the real root of the workforce shortage (low wages and morale, understaffing,
workplace culture), which has as much or more to do with retention as recruitment.
VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS
State of the Workforce
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Page 11, paragraph 293
The paragraph refers to “licensed” CNA’s, which may cause some confusion since CNA's are not licensed,
they are “certified.” We would recommend deleting the term “licensed” before “CNA" on lines 2 and 6 of
paragraph 2.
Student Outreach
Page 18, “Student Outreach”
The sentence under this heading/this section appears to be incomplete.
Supporting Veterans
Pages 25-26, “Supporting Veterans”
Paragraph 2 on page 26 contains the following statements:
DVS representatives also pointed out that neither CMS nor Virginia’s regulatory agencies recognize the civilian
equivalency of certain military allied health specialties; similarly, there is no standard recognition of military
medical education or awarding of equivalent credit hours.
Virginia’s health regulatory agencies do recognize substantially equivalent military education and training
of medical professionals as appropriate. The extent to which the training/education is recognized or applied to
requirements for licensure really depends upon the profession, the licensure qualifications, and the nature of
the military education/training.
Va. Code § 54.1-118 provides the following:
§ 54.1-118. Qualifications for licensure, etc.; substantially equivalent military training and education.
A. Except as provided in this section, the regulatory boards within the Department of Professional and
Occupational Regulation, the Department of Health Professions, or any board named in this title shall accept
the military training, education, or experience of a service member honorably discharged from active military
service in the armed forces of the United States, to the extent that such training, education, or experience is
substantially equivalent to the requirements established by law and regulations of the respective board for the
issuance of any license, permit, certificate, or other document, however styled or denominated, required for the
practice of any business, profession, or occupation in the Commonwealth. To the extent that the service member's
military training, education, or experience, or portion thereof, is not deemed substantially equivalent, the
respective board shall credit whatever portion of the military training, education, or experience that is
substantially equivalent toward meeting the requirements for the issuance of the license, permit, certificate, or
other document.
The provisions of this subsection shall not apply to the Board of Medicine in the regulation of the practice of
medicine or osteopathic medicine. Nor shall this subsection apply to the Board of Dentistry in the regulation of
dentists or oral and maxillofacial surgeons.
93 References to paragraphs and page numbers are for a prior draft and may no longer be accurate.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
B. The Board of Medicine may accept a service member's military training, education, or experience as an
intern or resident in an approved facility to satisfy the requirement of one year of satisfactory postgraduate
training as an intern or resident in a hospital or health care facility, provided the applicant for licensure (i) has
been honorably discharged from active military service in the armed forces of the United States, (ii) is a graduate
of a Board-approved institution, (iii) has successfully completed all required examinations for licensure, and (iv)
applies for licensure within six months of discharge from active military service.
C. The Board of Dentistry may accept the military training, education, or experience of a service member
provided the applicant for licensure (i) has been honorably discharged from active military service in the armed
forces of the United States, (ii) has been in continuous clinical practice for four of the six years immediately
preceding the application for licensure, (iii) holds a diploma or certificate of a dental program accredited by the
Commission on Dental Accreditation of the American Dental Association, and (iv) has successfully completed
all required examinations for licensure. Active patient care in the Dental Corps of the United States armed
forces, voluntary practice in a public health clinic, or practice in an intern or residency program may be accepted
by the Board to satisfy requirements for licensure.
D. Any regulatory board may require the service member to provide such documentation of his training,
education, or experience as deemed necessary by the board to determine substantial equivalency.
E. As used in this section, "active military service" means federally funded military duty as (i) a member of
the armed forces of the United States on active duty pursuant to Title 10 of the United States Code or (ii) a
member of the Virginia National Guard on active duty pursuant to either Title 10 or Title 32 of the United
States Code.
VIRGINIA HEALTH CARE ASSOCIATION | VIRGINIA CENTER FOR ASSISTED LIVING
Recommendation #12 – 16
Support provided funding is provided by GA which would only cover Medicaid, so the cost would be
passed through to the private pay residents.
Recommendation #23
Support in lieu of #22.
Recommendation #24
We fully agree in concept to a value-based payment arrangement whereby additional payment, relative to
the normal Medicaid rate, be provided based on achievement of or progress toward quality measures. In fact,
over a year ago we proposed that DMAS explore such an initiative by convening the Medicaid managed care
organizations and our organization to “to determine which existing long-term care quality performance metrics
should be measured; the methodology and thresholds for successful achievement or significant improvement
under which a facility would qualify for an enhanced, add-on payment; the distribution formula for the
enhanced payment; and, the funding mechanism to allow incorporation of the enhanced funding into MCO
capitation rates, or in any other federally-approved mechanism for full distribution to eligible nursing facilities.”
Our only concern with the recommendation as written is that while we do believe increased direct care hours
will likely be an end product of the initiative, if not an explicit measure, we do not believe the measures should
be formalized until the above process has taken place. However, we stand by the proposal and believe it is very
much on line with the spirit of the recommendation.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
A P P E N D I X H – S E RV I C E L E A R N I N G R E QU I R E M E N T S B Y J U R I S D I C T I O N
This chart outlines the high school graduation requirements or credit allowed toward graduation for
service-learning per jurisdiction. Per the Education Commission of the States, many school districts have
graduation requirements in addition to those required by the jurisdiction.94
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
AK No No No
AL No No No
AR No A student who has completed No
a minimum of 75 hours of
documented community
service in grades 9-12, as
certified to the school by the
service agency or organization,
is eligible to receive one
academic credit that may be
applied toward graduation.
The community service must
be in programs or activities
approved by the State Board
of Education and the local
school board and must include
preparation, action, and
reflection components. Local
school boards are authorized
to grant a waiver of this
requirement with notice to the
state board.
Ark. Code Ann. § 6-16-120
Code Ark. R. 005.08.1
AZ No No No
CA No No No
CO No No School districts are required to
consider and, if they deem it
appropriate, adopt a policy to
encourage students to engage
in community service or
service-learning and to
recognize students'
contributions to their
94 Baumann, Paul. “50-State Comparison: High School Graduation Requirement or Credit toward Graduation — Service-
Learning/Community Service.” Education Commission of the States. National Center for Learning and Civic
Engagement, January 1, 2014. http://ecs.force.com/mbdata/mbquest3RTE?Rep=SL1301.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
communities through
community service or service-
learning. A student who
successfully meets the
community service or service-
learning program goals can
earn recognition in the manner
described in the policy. The
policy should specify how the
service is recognized on a
student's diploma or transcript
as an indication of the
student's commitment to
service within the community.
Colo. Rev. Stat. Ann. § 22-32-
137
CT No A local or regional board of No
education is authorized to
offer one-half credit in
community service, which
qualifies for high school
graduation credit. The
community service must
supervised by a certified
school administrator or teacher
and consist of not less than 50
hours of actual service that
may be performed at times
when school is not regularly in
session and not less than 10
hours of related classroom
instruction. Community
service does not include
partisan political activities.
Beginning with classes
graduating in 2020, to
graduate, students will be
required to complete two
credits in career and life skills
electives, such as career and
technical education, English as
a second language, community
service, personal finance,
public speaking, and nutrition
and physical activity.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
Conn. Gen. Stat. Ann. § 10-
221a
DC Students are required to No No
complete 100 hours of
volunteer community service
to graduate. The specific
community service projects are
established by the local
education agency.
D.C. Mun. Regs. tit. 5-E §
2203
DE No If a student in grades 9-12 No
performs at least 45 hours of
voluntary community service
for 2 semesters, the student
will receive 1 Delaware
Volunteer credit. The credit
may be counted as an elective
for graduation requirements if
the service is approved by, and
conducted under the
supervision of, the school
principal. To qualify for the
credit:
The service must be
performed outside of the
hours during which the
student is required to be
at school. Service can be
performed during the
summer or other recess
periods.
The organization or
project with whom the
service is performed
must have its name
submitted to a school
guidance counselor by
the Delaware Office of
Tourism or the
Department of
Education.
The service cannot be of
a political or advocacy
nature.
A student can only be awarded
one Delaware Volunteer
credit.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
Del. Code Ann. tit. 14, §
8902A.
FL No Districts may award up to one- School districts are encouraged
half elective credit for student to include service learning as
completion of nonpaid part of any course or activity
voluntary community or required for high school
school service work. Students graduation and to include and
choosing this option must accept service-learning
complete a minimum of 75 activities and hours in
hours of service in order to requirements for academic
earn the one-half credit in awards, especially those awards
either category of instruction. that currently include
Credit may not be earned for community service as a
service provided as a result of criterion or selection factor.
court action. District school
boards that approve the award Fla. Stat. Ann. § 1003.497
of credit for student volunteer
service are required to develop
guidelines regarding the award
of the credit, and school
principals are responsible for
approving specific volunteer
activities.
Fla. Stat. Ann. § 1003.497
GA No Community Service I, II, III, No
and IV are elective courses
that satisfy credit requirements
for high school graduation.
Ga. Comp. R. & Regs. 160-4-
2-.36
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
HI No Beginning with the graduating No
class of 2016,95 one of the six
elective credits for graduation
may include one elective credit
for a senior project. The
components of a senior
project are:
Research Paper
Project (career focus,
service learning, or
student personal
interest)
Project Portfolio
Presentation to a panel
IA No No A school district or a
nonpublic school may require
a certain number of service-
learning units as a condition
for the inclusion of a service-
learning endorsement on a
student's diploma or as a
condition of graduation.
Iowa Code Ann. § 256.18A
ID No No No
IL No School districts are authorized No
to establish a volunteer service
credit program under which
students can earn credit
toward graduation through
performance of community
service. The amount of credit
given for program
participation cannot exceed
the amount given for
completion of one semester of
language arts, math, science, or
social studies.
105 ILCS 5/27-22.3
95 “Graduation Requirements.” Hawaii State Department of Education.
http://www.hawaiipublicschools.org/TeachingAndLearning/StudentLearning/GraduationRequirements/Pages/home.a
spx.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
IN No Students in grade 11 or 12 can No
earn academic credit toward
the student’s minimum
graduation requirements by
completing approved
community service or other
volunteer service.
Ind. Code Ann. § 20-30-14-1
The State Board of Education
is required to promulgate rules
related to community service.
Among the required rules are
requirements that a student
must perform at least 48 hours
of service to earn one
academic credit and that not
more than two academic
credits toward graduation may
be awarded.
Ind. Code Ann. § 20-30-14-9
KS No No No
KY No No No
LA No No No
MA No No No
MD Students are required to No No
complete either:
75 hours of student
service that includes
preparation, action, and
reflection components
and that, at the
discretion of the local
school system, may
begin during the middle
grades; or
a locally designed
program in student
service that has been
approved by the state
Superintendent of
Schools.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
Md. Code Regs. 13A.03.02.06
ME No No No
MI No No No
MN No A school board is authorized No
to offer, as part of a
community education program
with a youth development
program, a youth service
program that provides young
people with opportunities to
become involved in their
community, develop individual
capabilities, make career
connections, seek support
networks and services, become
active citizens, and address
community needs through
youth service. The board may
award up to one credit toward
graduation for a pupil who
completes the youth service
requirements of the district.
Minn. Stat. Ann. § 124D.19
MO No Local boards of education that No
maintain a high school are
authorized to include service-
learning as part of any course
contributing to the satisfaction
of credits necessary for high
school graduation and to
provide support for the use of
service-learning as an
instructional strategy at any
grade level to address
appropriate areas of current
state educational standards for
student knowledge and
performance.
Mo. Rev. Stat. § 170.037.3
MS No No No
MT No No No
NC No No No
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
ND No Two service learning courses No
listed in the high school career
and technical supplementary
services course codes for
grades 9-12 are designed to
help at-risk students make a
smooth, successful transition
from high school to the world
of work and will allow students
to earn elective credits toward
graduation requirements.96
NE No No No
NH No If a district chooses to offer No
extended learning
opportunities in middle school,
the opportunities must be
governed by a policy adopted
by the local school board that
specifies whether or not credit
can be granted for extended
learning activities, including,
but not limited to, independent
study, private instruction, team
sports, performing groups,
internships, community
service, and work study.
NH ADC ED 306.26
If a district chooses to offer
extended learning
opportunities in high school as
part of the required curriculum
content, the opportunities
must be governed by a policy
adopted by the local school
board that specifies that credits
can be granted for extended
learning activities, including
independent study, private
instruction, team sports,
performing groups,
internships, community
service, and work study.
96 “Grades 9-12 Course Codes: Career and Technical Supplementary Services.” North Dakota Department of Public
Instruction, July 2013. http://www.dpi.state.nd.us/resource/corscode/2014pdf/specneeds14.pdf.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
NH ADC ED 306.27
NJ No The 120-credit requirement for No
graduation may be met in
whole or in part through
completion of a range of
experiences that enable
students to pursue a variety of
personalized learning
opportunities. District boards
of education are required to
establish a process to approve
individualized student learning
opportunities, including
service-learning experiences,
that meet or exceed the core
curriculum content standards.
N.J. Admin. Code 6A:8-5.1
NM No School districts must offer No
student service learning as an
elective in which students can
earn credits toward the elective
units required for graduation.
N.M. Stat. Ann. § 22-13-1.1
Among the items allowed for
alternate demonstration of
competency of high school
exit requirements using
standards-based indicators are
community-based projects
such as internships, service
learning, pre-apprenticeship, or
after-school job performance.
N.M. Admin. Code § 6.19.7
A career readiness alternative
program of study leading to a
diploma or conditional
certificate of transition is
available to students with an
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
IEP. Course work includes a
minimum of four units of
career development
opportunities and learning
experiences that may include
career readiness and vocational
course work, work experience,
community-based instruction,
student service learning, job
shadowing, mentoring, or
entrepreneurships related to
the student's occupational
choices.
N.M. Admin. Code § 6.29.1
NV No High school students who No
successfully complete an
approved community service
project are allowed to apply
not more than one credit
received for the completion of
the project toward the total
number of credits required for
graduation. The credit must be
applied toward the pupil's
elective course credits and not
toward a course that is
required for graduation from
high school.
Nev. Rev. Stat. 389.165
NY No No No
OH No High school credit for a No
community service education
course may be granted if
approximately half of the
course is devoted to classroom
study of such matters as civic
responsibility, the history of
volunteerism, and community
service training and
approximately half of the
course is devoted to
community service.
Ohio Rev. Code Ann. §
3313.605
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
OK No School districts are authorized No
to establish, as part of the
curriculum, a youth
community service program
for secondary students that
includes youth community
service activities integrated
with study and reflection on
the experiences gained through
youth community service
activities. Students may receive
elective credit for participating
in a youth community service
program as long as the
outcomes of the program
reflect the competencies
outlined in the Oklahoma
Learner Outcomes adopted by
the State Board of Education.
A student may perform youth
community service activities
for credit only under the
sponsorship of an organization
approved by the State
Department of Education.
Okla. Stat. Ann. tit. 70, § 11-
108.2 West
OR No Students have the option of No
earning credit required for a
diploma or a modified diploma
by successfully completing
classroom or equivalent work
(e.g., supervised independent
study, career-related learning
experiences, project-based
learning) in a course of at least
130 clock hours. The work
must meet common
curriculum goals and academic
content standards.
Or. Admin. R. 581-022-1131
PA No No No
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
RI No No The Department of
Elementary and Secondary
Education is required to
encourage school districts to
establish community service
learning programs by
developing a model program
and appropriate guidelines for
implementation of the model
program. Local school districts
may petition the
Commissioner of Education
for approval of community
service learning programs,
which may be used in partial
fulfillment of the requirement
for obtaining a high school
diploma. The commissioner
must develop criteria that
school districts can use as a
means of determining and
recognizing community service
learning activities for credit
towards a high school diploma.
R.I. Gen. Laws Ann. § 16-22-
21
SC No No No
SD No Students are required to No
complete at least one unit, in
any combination, of approved
career and technical education
courses, a capstone experience
or service learning, and world
languages.
S.D. Admin. R. 24:43:11:02
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
TN No Local boards of education set Local boards of education are
the number of credit hours encouraged to consider
that may be earned by students requirements for students to
who complete a minimum of complete a capstone
30 service hours in the course experience. Capstone
“Success Skills through Service experiences may include,
Learning.”97 A maximum of among other things, at least 40
three credits may be earned in hours of service learning or
any one school year, and at community service.
least one credit must be earned
in the related classroom Tenn. Comp. R. & Regs. 0520-
experience. Credit is not 01-03-.06
awarded for paid service
learning.98
TX No One-half to one credit is No
awarded for a family and
community services course
that is designed to involve
students in realistic and
meaningful community-based
activities through direct service
experiences. Students are
provided opportunities to
interact and provide services to
individuals, families, and the
community through
community or volunteer
services. Emphasis is placed
on developing and enhancing
organizational and leadership
skills and characteristics.
19 Tex. Admin. Code §
130.249
One-half to one credit is
awarded for the principles of
hospitality and tourism course
and the travel and tourism
management course. Students
must demonstrate leadership,
citizenship, and teamwork
skills required for success, and
97 “Success Skills Through Service Learning.” Tennessee Department of Education.
http://www.tn.gov/education/ci/service/doc/SL_Grades_9-12.pdf.
98 “Work-Based Learning Policies, Procedures, and Resources.” Tennessee Department of Education, April 2013.
http://www.tennessee.gov/education/cte/wb/doc/WorkBasedLearningPoliciesApril2013.pdf.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
they are expected to participate
in community service activities.
19 Tex. Admin. Code §
130.222
19 Tex. Admin. Code §
130.225
UT No No No
VA No No No
VT No No No
WA No School districts are required to No
adopt a policy that is
supportive of community
service and provides an
incentive, such as recognition
or credit, for students who
participate in community
service.
WA ST 28A.320.193
WI No No A school board may require a
pupil to participate in
community service activities in
order to receive a high school
diploma.
Wis. Stat. Ann. § 118.33
WV No Students in grades 9-12 must No
be provided structured, on-
going experiences for career
exploration, decision making,
and career preparation. All
students must participate in an
experiential learning
experience at some time in
grades 9-12. If credit is granted
for these experiences, content
standards and objectives will
be developed and approved at
the local level. Experiential
learning is defined as
structured work-based,
services-based, community-
based, or research-based
learning experiences.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Statewide Requirement Credit toward graduation Local districts discretion to adopt
diction requirement
W. Va. Code R. § 126-42-5
W. Va. Code R. § 126-42-13
WY No No No
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
APPENDIX I – N U R S I N G H O M E S TA F F I N G R E Q U I R E M E N T S B Y J U R I S D I C T I O N
This chart outlines the minimum staffing ratios and minimum direct care hours for licensed nursing homes
per jurisdiction. Minimum direct care hours requirements are often presented as hours per resident day
(HPRD).
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
AK Day Shift: 1 RNs to every 30 residents N/A
Other Shifts: 1 RN to every 60 residents
Alaska Admin. Code, tit. 7, § 12. 275
AL N/A N/A
AR Day Shift: 1 direct care staff per 6 residents; 1 N/A
licensed nurse per 40 residents
Evening Shift: 1 direct care staff per 9 residents;
1 licensed nurse per 40 residents
Night Shift: 1 direct care staff per 14 residents;
1 licensed nurse per 80 residents
Ark. Code R. § 016.06-15-520.3.1
AZ 1 licensed nurse per 64 residents N/A
Ariz. Admin. Code § R9-10-412(B)(3)
CA N/A 3.5 HPRD, with a minimum of 2.4 HPRD by
CNA
Cal. Code Regs., tit. 22, § 72329.2
CO N/A 2.0 HPRD
10 Colo. Code Regs. § 2505-10-8-408
CT N/A Day Shift: 1.40 HPRD for licensed nurses and
nurse aides, with 0.47 HRPD for licensed
nurses
Night Shift: 0.50 HPRD for licensed nurses and
nurse aides, with 0.17 HRPD for licensed
nurses
Conn. Agencies Regs., § 19-13-D8t(m)
DC N/A Minimum daily average of 4.1 HPRD, with 0.6
HPRD provided by an RN or advance practice
RN and 0.2 HPRD provided by a physician,
PA, or advanced practiced RN
D.C. Mun. Regs. tit. 22B, § 3211.4 – .5
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
DE Day Shift: 1 RN or LPN per 15 residents; 1 3.67 HPRD
CNA per 7 residents
Evening Shift: 1 RN or LPN per 20 residents; 1 Del. Code tit 16, § 1162(e)
CNA per 10 residents
Night Shift: 1 RN or LPN per 30 residents; 1
CNA per 15 residents
Del. Code tit 16, § 1162(e)
FL 1 CNA per 20 residents Minimum weekly average of 3.6 HPRD
1 licensed nursing per 40 residents. combined licensed nurse and CNA staffing,
with 2.5 HPRD for CNAs and 1.0 HRPD for
Fla. Stat. § 400.23(3)(a)(1)(c) – (d) licensed nurses
Fla. Stat. § 400.23(3)(a)(1)(a) – (b)
GA N/A 2.0 HPRD
Ga. Comp. R. & Regs. 111-8-56-.04
HI N/A N/A
IA N/A 2.0 HPRD, or 1.7 HPRD if maximum medical
assistance rate is reduced below the 74th
percentile
Iowa Admin. Code r. 481-58.11(2)(g)
ID N/A 2.4 HPRD
Idaho Admin. Code r. 16.03.02.200.02(d)
IL N/A 3.8 HPRD for skilled care and 2.5 HPRD for
nonskilled care, with at least 25% being
provided by a licensed nurse and at least 10%
being provided by an RN
Il. Admin. Code tit. 77, pt. 300.1230(c) – (d)
IN N/A N/A
KS 1 licensed nurse per 30 residents Minimum weekly average of 2.0 HRPD
Minimum daily average of 1.85 HRPD
Kan. Admin. Regs. § 28-39-154(a)(7)(B)
Kan. Admin. Regs. § 28-39-154(a)(7)(A)
KY N/A N/A
LA N/A 2.35 HPRD
La. Admin. Code tit. 48, § 9823
MA N/A N/A
MD 1 nursing service personnel per 15 residents 3.0 HPRD
1 RN per 99 residents
Md. Code Regs. 10.07.02.19(B)
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
Md. Code Regs. 10.07.02.19(A) and (D)
ME Day Shift: 1 direct-care provider per 5 residents N/A
and
20 or fewer beds: 1 licensed nurse; or
Greater than 20 beds: 1 licensed nurse,
with an additional licensed nurse for each
50 beds above 50 and with an additional
RN for every 100 beds
Evening Shift: 1 direct-care provider per 10
residents and 1 licensed nurse per shift, with an
additional licensed nurse for each 70 beds and
with an additional RN for every 100 beds
Night Shift: 1 direct care provider per 15
residents and 1 licensed nurse per shift, with an
additional licensed nurse for each 100 beds and
with an additional RN for every 100 beds
10 144 Me. Code R. 110 § 9.A.3 and .4
MI Day Shift: 1 nursing care personnel per 8 2.25 HPRD
residents
Evening Shift: 1 nursing care personnel per 12 Mich. Comp. Laws § 333.21720a(2)
residents
Night Shift: 1 nursing care personnel per 15
residents
Mich. Comp. Laws § 333.21720a(2)
MN N/A 2.0 HPRD
Minn. Stat. § 144A.04(7)(a); Minn. R. 4658.0510
MO N/A N/A
MS N/A 2.8 HPRD
Miss. Code R. § 45.4.1(1)
MT Day Shift: N/A
4-8 beds: 1 RN
9-15 beds: 1 RN and 0.5 CNA
16-20 beds: 1 RN and 1 CNA
21-25 beds : 1 RN and 1.5 CNAs
26-30 beds : 1 RN and 2 CNAs
31-35 beds : 1 RN and 2.5 CNAs
36-40 beds : 1 RN and 3 CNAs
41-45 beds : 1 RN, 1 LPN, and 3.5 CNAs
46-50 beds : 1 RN, 1 LPN, and 4 CNAs
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
51-55 beds: 1 RN, 1 LPN, and 4.5 CNAs
56-60 beds: 1 RN, 1 LPN, and 5 CNAs
61-65 beds: 1 RN, 1 LPN, and 5.5 CNAs
66-70 beds: 1 RN, 1 LPN, and 6 CNAs
71-75 beds: 1 RN, 1 LPN, and 6.5 CNAs
76-80 beds: 1 RN, 2 LPNs, and 6 CNAs
81-85 beds: 1 RN, 2 LPNs, and 6.5 CNAs
86-90 beds: 1 RN, 2 LPNs, and 7 CNAs
91-95 beds: 2 RNs, 2 LPNs, and 6.5 CNAs
96-100 beds: 2 RN, 2 LPNs, and 7 CNAs
101+ beds: Individually determined
Evening Shift:
4-15 beds: 1 LPN
16-20 beds: 1 LPN and 0.5 CNA
21-30 beds : 1 LPN and 1 CNA
31-35 beds : 1 LPN and 1.5 CNAs
36-45 beds : 1 LPN and 2 CNAs
46-50 beds : 1 LPN and 2.5 CNAs
51-60 beds: 1 RN and 3 CNAs
61-65 beds: 1 RN and 3.5 CNAs
66-75 beds: 1 RN and 4 CNAs
76-90 beds: 1 RN, 1 LPN, and 4 CNAs
91-95 beds: 1 RN, 1 LPN, and 4.5 CNAs
96-100 beds: 1 RN, 1 LPN, and 5 CNAs
101+ beds: Individually determined
Night Shift:
4-20 beds: 1 LPN
21-25 beds : 1 LPN and 0.5 CNA
26-40 beds : 1 LPN and 1 CNA
41-45 beds : 1 LPN and 1.5 CNAs
46-60 beds : 1 LPN and 2 CNAs
61-65 beds: 1 LPN, and 2.5 CNAs
66-70 beds: 1 LPN and 3 CNAs
71-80 beds: 1 RN and 3 CNAs
81-85 beds: 1 RN, 1 LPN, and 2.5 CNAs
86-100 beds: 1 RN, 1 LPN, and 3 CNAs
101+ beds: Individually determined
Mont. Admin. R. 37.106.605(1)99
99 Montana expresses staffing standards as minimum number of hours provided by each category of nursing staff per shift
per licensed bed. For ease of comparison, these standards have been translated into the equivalent amount of FTE.
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
NC N/A N/A
ND N/A N/A
NE N/A N/A
NH N/A N/A
NJ N/A 2.5 HRPD for all residents and
0.75 HPRD for wound care
1 HPRD for Nasogastric tube feedings
and/or gastrostomy
0.75 HPRD for oxygen therapy
1.25 HPRD for tracheostomy
1.5 HPRD for intravenous therapy
1.25 HPRD for use of respirator
1.5 HRPD for head trauma
stimulation/advanced
neuromuscular/orthopedic care
N.J. Admin. Code §§ 8:39-25.2(b) and 8:85-
2.2(a)
NM N/A Weekly minimum average of 2.5 HPRD
N.M. Code R. § 7.9.2.51(F)(2)(a)
NV N/A N/A
NY N/A N/A
OH N/A 2.5 HPRD
Ohio Admin. Code 3701:17-08
OK Day Shift: 1 direct care provider per 7 residents Depending on the state Medicaid
Evening Shift: 1 direct care provider per 10 reimbursement rate, 2.86 HPRD, 3.2 HPRD,
residents 3.8 HPRD, or 4.1 HPRD
Night Shift: 1 direct care provider per 17
residents Okla. Stat. tit. 63, § 1-1925.5(B)(5)(a) and (F)(1)
– (3)
Okla. Stat. tit. 63, § 1-1925.5(B)(3)
OR Day Shift: 1 CNA per 7 residents 1 RN hour per resident per week
Evening Shift: 1 CNA per 9.5 residents
Night Shift: 1 CNA per 17 residents Or. Admin. R. 411-086-0100(4)(a)
Or. Admin. R. 411-086-0100(5)(c)
PA 1 licensed nurse per 20 residents at all times and 2.7 HPRD
Day Shift:
o 150 or fewer residents: 1 RN 28 Pa. Code § 211.12(i)
o 151 – 250 residents: 1 RN and 1 LPN
o 251 – 500 residents: 2 RNs
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
o 501 – 1,000 residents: 4 RNs
o 1,001 or more residents: 8 RNs
Other Shifts:
o 150 or fewer residents: 1 RN
o 151 – 250 residents: 1 RN and 1 LPN
o 251 – 500 residents: 2 RNs
o 501 – 1,000 residents: 3 RNs
o 1,001 or more residents: 6 RNs
28 Pa. Code § 211.12(f)(1) and (g)
RI N/A N/A
SC 1 licensed nurse per shift (except if there are 45 N/A
or more residents, there will be 2 licensed
nurses on the Day Shift) and
Day Shift: 1 nonlicensed nursing staff per 9
residents
Evening Shift: 1 nonlicensed nursing staff
per 13 residents
Night Shift: 1 nonlicensed nursing staff per
22 residents
S.C. Code Regs. 61-17-605(A)(2) and (B)(1)
SD N/A N/A
TN N/A 2.0 HPRD, with 0.4 HPRD from a licensed
nurse
Tenn. Comp. R. & Regs. 1200-08-06-.06
TX 1 licensed nursing staff per 20 residents 0.4 HPRD
26 Tex. Admin. Code § 544.1002(a)(1) 26 Tex. Admin. Code § 544.1002(a)(1)
UT N/A N/A
VA N/A N/A
VT N/A Minimum weekly average of 3.0 HPRD, with
2.0 HRPD provide by licensed nurse aides
Vt. Code R. 13-110-005.7.13(c)(3)(d)(1)
WA N/A 3.4 HPRD
Wash. Rev. Code § 74-42-360(2)
WI Day Shift: 1 RN irrespective of resident census N/A
Other Shifts: 1 RN per shift in nursing homes
with 75 or more residents
Wis. Admin. Code DHS § 132.62(2)(b)(1)
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GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
Juris- Minimum Staffing Ratio Minimum Direct Care Hours
diction
WV N/A 2.25 HPRD
W. Va. Code R. § 64-13-8.14.a100
WY N/A 2.25 HPRD for skilled care and 1.5 HPRD for
nonskilled care
048-003-011 Wyo. Code R. § 9(x)
100 West Virginia publishes a multi-page table in its regulations (Table 64-13A) that details individual staffing per day and
hours per day by individual resident count so that nursing homes know the minimum care staff to employ to meet the
prescribed minimum direct care hours. Due to the table’s length, it has not been reproduced in this appendix, but can be
accessed at this link (https://apps.sos.wv.gov/adlaw/csr/readfile.aspx?DocId=26551&Format=PDF).
72
GA Report – Availability of Clinical Workforce for Nursing Homes, 2020
APPENDIX J – C NA R E S P ON S E S TO D I G N I T Y F O R T H E A G E D
The following materials were provided to VDH staff by Dignity for the Aged and was prepared by a Dignity
for the Aged member who had solicited this information from 100 CNAs via Facebook, in response to the
question, “If you have ever considered leaving the CNA profession (or already have), what were your main
reasons why?” Questions about the information presented in this Appendix should be directed to Dignity for
the Aged.
CNA Survey Data
100 Responses (%)
70
59
60
51
50
41
40
33
30
20 15
10
0
Low Wages Burnout/Understaffed Physical Issues Lack of Appreciation Co-worker Issues
A Closer Look
Low Wages – 59% Physical Issues – 41%
- CNA income in VA: $14.61/hour or - 41 CNAs in this survey report consistent
$28,599/year wear and tear on their body, back pain,
- Average income in VA: $72,577/year knee pain, and foot pain
- Virginia ranks 31st in cost of living with - Because of understaffing, it is often hard
1st being most affordable to find help for the very physical tasks
- Minimum wage in VA: $7.25/hour and that need more than one person
will rise over the next 2.5 years to
$12.00/hour Lack of Appreciation – 33%
- For comparison: Target’s starting wage as - 1/3 of the CNAs feel they are not
of July 5 is $15.00 appreciated by their administration
and/or the nurses
Burnout/Understaffed – 51%
- Most CNAs report having to care for 20+ Co-Worker Issues – 15%
residents during a normal shift - 15 of the CNAs cited workplace drama
- It is also common for CNAs to report and lack of teamwork as a reason for
times when they have had to care for 30 – leaving
60 residents because of severe
understaffing, callouts, etc.
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