Workforce Challenges in Virginia's Nursing Homes — Joint Commission on Health Care Report #464 (2021)
Summary
Report Document #464 to the Governor and the General Assembly of Virginia from the Joint Commission on Health Care, titled Workforce Challenges in Virginia's Nursing Homes and dated October 2021. Its In Brief section states that 21 percent of facilities are not providing enough hours of direct care, and that more than 60 percent of facilities with low staffing receive poor health inspection ratings. It names a shortage of certified nursing assistants (CNAs) as the biggest challenge for Virginia's nursing homes. Policy options listed include increasing Medicaid reimbursement for nursing homes with a high Medicaid population (Option 1) and requiring all nursing homes to meet a baseline staffing level (Options 2 and 3).
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JOINT COMMISSION ON HEALTH CARE
WORKFORCE CHALLENGES IN VIRGINIA’S NURSING HOMES
REPORT TO THE GOVERNOR AND THE
GENERAL ASSEMBLY OF VIRGINIA
REPORT DOCUMENT #464
COMMONWEALTH OF VIRGINIA
RICHMOND
2021
Code of Virginia § 30-168. Joint Commission on Health Care
The Joint Commission on Health Members
Care (the Commission) is
Chair
established in the legislative branch
The Honorable Delegate Patrick A. Hope
of state government. The purpose
of the Commission is to study, Vice Chair
report and make recommendations The Honorable Senator George L. Barker
on all areas of health care
provision, regulation, insurance, Senate of Virginia
liability, licensing, and delivery of Senator Siobhan S. Dunnavant
services. In so doing, the Senator John S. Edwards
Commission shall endeavor to
Senator Barbara A. Favola
ensure that the Commonwealth as
provider, financier, and regulator Senator Ghazala F. Hashmi
adopts the most cost-effective and Senator Jen A. Kiggans
efficacious means of delivery of
Senator Jennifer L. McClellan
health care services so that the
greatest number of Virginians Senator David R. Suetterlein
receive quality health care. Further,
the Commission shall encourage Virginia House of Delegates
the development of uniform Delegate Dawn M. Adams
policies and services to ensure the Delegate Emily M. Brewer
availability of quality, affordable
Delegate C. Matthew Fariss
and accessible health services and
provide a forum for continuing the Delegate C.E. (Cliff) Hayes, Jr.
review and study of programs and Delegate M. Keith Hodges
services.
Delegate Robert D. Orrock, Sr.
The Commission may make Delegate Sam Rasoul
recommendations and coordinate
Delegate Ibraheem S. Samirah
the proposals and
recommendations of all Delegate Mark D. Sickles
commissions and agencies as to
Staff
legislation affecting the provision
and delivery of health care. For the Jeff Lunardi
purposes of this chapter, “health Executive Director
care” shall include behavioral Stephen G. Weiss, M.P.A.
health care. Senior Health Policy Analyst
Kyu Kang
Associate Health Policy Analyst
Estella Obi-Tabot, MSPH
Associate Health Policy Analyst
Ashley Williams (VMF)
Assistant Health Policy Analyst
Agnes Dymora
Executive Assistant/Office Manager
Workforce Challenges in Virginia’s
Nursing Homes
Contents
In Brief................................................................................................................................... i
Study purpose ...................................................................................................................... 1
Staffing is a challenge across Virginia nursing homes ......................................................... 2
Low staffing increases the risk of low-quality care.............................................................. 7
Workforce shortage contributes to inadequate staffing ................................................... 17
Additional strategies could incentivize better staffing and care quality ........................... 22
Appendix 1: Nursing homes in Virginia ............................................................................. 27
Appendix 2: CMS Five-Star Quality Rating System ............................................................ 29
Appendix 3: Average nursing home acuity ........................................................................ 32
Appendix 4: Complaints to the Virginia LTC Ombudsman................................................. 34
Appendix 5: Study Resolution............................................................................................ 36
Workforce Challenges in
Virginia’s Nursing Homes
POLICY OPTIONS IN BRIEF FINDINGS IN BRIEF
There are 8 policy options in the One-fifth of Virginia’s nursing homes are not meeting expected
report for Member consideration. staffing levels, disproportionately impacting low-income residents
Below are highlighted options. All nursing homes in Virginia struggle to recruit and retain staff, and
21 percent of facilities are not providing enough hours of direct
Option: Increase Medicaid care. A shortage of certified nursing assistants (CNAs), who provide
reimbursement for nursing homes a majority of direct patient care, is the biggest challenge for
with a high Medicaid population Virginia’s nursing homes. In general, facilities with fewer staff also
(Option 1, page 6). have a higher concentration of Medicaid recipients and Black
residents.
Option: Require all nursing homes
to meet a baseline staffing level Low staffing increases the risk of low-quality care
using an across-the-board standard
More than 60 percent of facilities with low staffing receive poor
or an acuity-based standard
health inspection ratings, which include criteria such as medication
(Options 2 and 3, pages 13-14).
management and resident quality of life. When staffing falls below a
minimum threshold, it becomes increasingly difficult for staff to
Option: Fund evaluation of
manage the workload and provide quality care, leading to burnout
incentive payments for nursing
that exacerbates these challenges. Increasing the number of hours
homes that meet higher staffing
of direct care per resident is shown to improve clinical outcomes
levels, above the required baseline
and resident satisfaction.
(Option 7, page 23).
Shrinking workforce is a contributing factor to staffing challenges
Option: Implement workforce
development programs, including There are a decreasing number of (LPNs) and CNAs in Virginia.
loan repayment and leadership Recruitment can be difficult as nursing home jobs are considered
development less desirable, compared to other health care settings. Retention is
(Options 5 and 6, pages 21). dependent on wages, benefits, training and advancement
opportunities, workplace culture, and leadership. The COVID-19
Option: Develop a plan to increase pandemic significantly exacerbated existing workforce challenges.
Medicaid reimbursement for
residents with specific behavioral Residents’ behavioral health needs are not adequately accounted
health diagnoses for in reimbursement rates
(Option 8, page 24). An increasing number of nursing home residents have behavioral
health needs that require additional time and attention from staff.
Providing quality care to these residents requires increased staff
time, but current Medicaid reimbursement rates do not fully
compensate for these needs.
October 2021 i JCHC Analyst: Kyu Kang
Workforce Challenges in Virginia’s
Nursing Homes
Nursing home operators and resident advocates have been concerned about staffing
challenges in Virginia’s nursing homes for more than twenty years. The COVID-19
pandemic exacerbated many of these existing issues, and in December of 2020 the Joint
Commission on Health Care directed staff to study staffing in Virginia’s nursing homes and
its impact on the quality of care residents receive. (See Appendix 5 for JCHC study
resolution.) Specifically, the study resolution directed staff to:
• Assess the extent to which there are staffing shortages for nursing homes in Virginia
and understand the underlying causes;
• Evaluate the impact of staffing shortages on the quality of care provided in nursing
homes;
• Analyze whether these impacts are disproportionately impacting certain
populations in Virginia based on race, socioeconomic status, or other factors;
• Assess whether Virginia’s current licensing requirements and oversight are
appropriately identifying and addressing quality of care issues in nursing homes;
and
• Identify strategies to improve recruitment and retention of the necessary workforce.
1
Workforce Challenges in Virginia’s Nursing Homes
Staffing is a challenge across Virginia nursing homes,
particularly for those serving low-income residents
In Virginia, many facilities have difficulty with recruitment and
Different Types of Nursing retention of nursing staff. Staffing is a major component of
Homes quality care, and a significant body of research has found that
Nursing homes can be for- sufficient staffing is important for high-quality care. Direct care
profit, non-profit, or
government-owned. They may
staff, comprised of registered nurses (RNs), licensed practical
be independent, standalone nurses (LPNs), and certified nurse aides (CNAs) provide
facilities or be part of larger essential services to residents, which include managing
multi-facility chains. medications and assisting with mobility and other daily
Nursing homes that activities. Regardless of payer mix, size, facility structure, and
participate in Medicare and/or
Medicaid are called certified
other factors, all nursing homes need appropriate staffing,
facilities. Most nursing homes commensurate with the needs of their residents, to ensure
in Virginia (more than 90%) quality resident care.
are certified for both, with a
small group that take only
Medicare or only Medicaid.
One-fifth of Virginia’s nursing homes are not meeting
There are also a handful of CMS expectations for total direct care hours per
nursing homes that take no resident
federal dollars at all. (See
Appendix 1 for a breakdown As of August 2021, 21% of Virginia’s nursing homes reported
of Virginia’s nursing homes.) total nursing hours that fell short of the expected hours
calculated by the Centers for Medicare and Medicaid Services
(CMS). These shortfalls vary greatly by type of staff (FIGURE
1), with the shortfall being greatest for CNA hours. Statewide,
Hours Per Resident Day 59% of facilities reported CNA hours that were less than those
(HPRD)
expected by CMS; 25% reported less RN hours than expected;
CMS calculates the number of
and 7% reported insufficient LPN hours.
hours that should be provided
for each participating nursing As a result of these staffing shortages, 43% of Virginia’s
facility based on the acuity of
nursing homes received a 1- or 2-star Staffing rating from CMS,
its residents. This is measured
using ‘hours per resident indicating inadequate staffing. By comparison, across the U.S.,
day’(HPRD), and the results 31% of nursing homes received a 1- or 2-star Staffing rating
are factored into each (FIGURE 2).
facility’s Staffing star rating.
Nursing homes that do not CMS uses a Five-Star Quality Rating System for facility
participate in Medicaid and/or performance based on staffing, health inspections, and quality
Medicare do not have to
report the hours of care they
measures. A 3-star score indicates that the facility is generally
provide and are not subject to meeting but not exceeding expectations. A score of 1 or 2 stars
CMS ratings. generally means that the facility is performing below average
and needs to improve. (See Appendix 2 for more information
on how CMS assigns Staffing star ratings.)
2
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 1: Shortages are occuring in all nursing categories, and greatest shortage is
of CNA staff (2021)
SOURCE: Centers for Medicare & Medicaid Services Nursing Home Compare, “Provider Information.” Updated
August 1, 2021. Data includes all certified nursing facilities, some of which are not licensed as nursing homes by
the Virginia Department of Health (e.g., long-term care units operating inside hospitals). Data do not include any
information about nursing homes that are not certified.
FIGURE 2: Virginia has more facilities with low staffing ratings than other states
(2021)
SOURCE: Centers for Medicare & Medicaid Services Nursing Home Compare, “Provider Information.” Updated
August 1, 2021. Data includes all certified nursing facilities in Virginia, some of which are not licensed as nursing
homes by the Virginia Department of Health (e.g., long-term care units operating inside hospitals). Data do not
include any information about nursing homes that are not certified.
3
Workforce Challenges in Virginia’s Nursing Homes
Some nursing homes in Virginia are not staffing as high as their average resident acuity
requires, leading to lower CMS staffing ratings. On average, nursing homes in Virginia have
higher average acuity residents than nursing homes in most other states, and higher acuity
requires more skilled staff hours. For example, although nursing facilities in Virginia and
Massachusetts both provided an average of 0.52 hours of RN care per resident in 2018,
average acuity in Virginia is higher than in Massachusetts. (See Appendix 3 on nursing
home resident acuity across states.)
In interviews, leadership and staff of Virginia nursing homes agreed that lack of staffing is a
serious problem. There was consensus that workforce shortages are at the heart of the
issue, but the facility-level data indicate that most Virginia nursing homes (79%) are able to
overcome the shortages and meet minimum staffing levels based on CMS expectations.
Staffing shortages disproportionately impact facilities with low-income and
Black residents
Nursing homes in Virginia with a higher proportion of Medicaid residents have lower
staffing levels, on average (FIGURE 3). Additionally, facilities with a higher percentage of
Medicaid residents on average receive lower health inspection and quality ratings from
CMS. This is in line with national trends – across the U.S., states with a relatively larger
percentage of low-income residents also have more nursing homes with lower overall
ratings.
Medicaid is the primary payer for two-thirds of nursing home
The CMS Minimum Data Set residents in Virginia. As Medicaid reimbursements are designed
(MDS) captures resident
race/ethnicity by asking to just cover costs, not to be profitable, most nursing homes
residents to identify the balance a payer mix that includes Medicare and private-pay
race/ethnicity category that residents. Facilities that take on a greater proportion of
they identify with. If the
Medicaid residents may not have the financial resources to hire
resident cannot respond, and
no family member or more staff or raise wages.
significant other is available to
Fewer older Black adults have private insurance than white
respond, the resident’s
medical record adults and are more likely to be reliant on Medicaid. Nationwide,
documentation or observer Black nursing home residents are much more likely to be in
identification may be used. nursing homes where the majority of residents are supported by
Medicaid.
4
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 3: Facilities in Virginia with a high percentage of Medicaid residents tend to
have fewer direct care staff (2018)
Direct care hours per resident day
7
6
5
4
3
2
1
0
0 20 40 60 80 100
Percentage of Medicaid Residents
SOURCE: LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a
cooperative agreement with the Brown University School of Public Health. State data from 2018.
Nursing homes in Virginia with a higher proportion of Black residents also have lower
overall staffing numbers (FIGURE 4). Though Black residents represent just under 16% of
Virginia’s total senior population (age 65+), they make up 37% of Virginia’s Medicaid
enrollees. Additionally, nursing homes with a higher percentage of Black residents on
average receive lower health inspection and quality measures ratings from CMS. This is in
line with national trends that indicate Black nursing home residents are more likely to be in
facilities that have health deficiencies, that are involuntarily or voluntarily terminated from
participation in Medicare and Medicaid, and that are understaffed relative to resident
acuity.
5
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 4: Facilities in Virginia with more Black residents have lower average direct-
care staff HPRD (2018)
Average direct care staff hours per resident day
3.88 3.70
3.11 2.96
0-20% 20-40% 40-60% 60-80%
Percentage of Black Residents
SOURCE: LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a
cooperative agreement with the Brown University School of Public Health. State data from 2018.
NOTE: Black residents were identified as those who marked “Black, not of Hispanic origin” on their MDS
assessment. White residents were identified as those who marked “White, not of Hispanic origin” on their MDS
assessment. If race was missing on the assessment, race was drawn from the Medicare denominator file to
calculate the proportion of residents in a facility.
Raising Medicaid reimbursement rates for nursing homes with a high
concentration of Medicaid beds could improve staffing
Increasing Medicaid reimbursement rates for facilities that have a disproportionately high
percentage of Medicaid residents would provide additional resources to invest in staffing.
Nursing homes in which 70% or more of the residents receive coverage through Medicaid
could receive an additional per diem add-on payment, similar to the COVID-19 pandemic
add-on rates. Or, nursing homes could all receive an adjustment based on the percentage of
Medicaid recipients in their facility. For example, in Colorado, publicly owned nursing
homes receive supplemental payments for Medicaid residents, which bring their
reimbursement closer to Medicare payment rates.
Research shows that higher Medicaid reimbursement rates are associated with better
staffing and care quality. Increasing reimbursement rates, staffing, and quality would
provide greater benefit to facilities with higher concentrations of minorities.
OPTION 1: JCHC could introduce a budget amendment to include language in the
Appropriation Act directing Department of Medical Assistance Services (DMAS) to develop
a plan to increase nursing home reimbursement rates for nursing homes with a
disproportionate share of Medicaid residents.
6
Workforce Challenges in Virginia’s Nursing Homes
Low staffing increases the risk of low-quality care
JCHC staff analyzed the relationship between staffing and care quality in Virginia’s nursing
homes by looking at average staffing levels, health inspection scores, and quality ratings.
While higher staffing levels are strongly correlated with better resident outcomes, the
relationship is not always directly linear. There are many variables that influence both
staffing and facility performance, and it is important to understand to what extent staffing
shortages are truly affecting care in Virginia’s nursing homes in order to tailor potential
solutions.
Facilities with the fewest staff per resident are more likely to have lower health
inspection and quality ratings
Virginia nursing homes with lower staffing are more likely to have lower health inspection
scores (FIGURE 5). More than 60% of facilities with staffing that results in a 1- or 2-star
rating, also have a 1- or 2-star rating on their health inspection criteria. CMS Health
Inspection ratings are based on the number, scope, and severity of deficiencies identified in
a facility, as well as a weighted average of a facility’s three most recent health inspections
and complaint investigations. Ratings are assigned on a curve based on a facility’s relative
performance compared to other nursing homes in the state. Direct care staff play an
important role in facilities’ health inspection performance, as investigators assess
residents’ quality of life, medication management, and skin care, among other factors. (See
Appendix 2 for more information on CMS Health Inspection factors.)
7
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 5: Facilities in Virginia with lower staffing ratings are more likely to have low
health inspection ratings (2021)
SOURCE: Centers for Medicare & Medicaid Services Nursing Home Compare, “Provider Information.” Updated
August 1, 2021. Data includes all certified nursing facilities in Virginia, some of which are not licensed as nursing
homes by the Virginia Department of Health (e.g., long-term care units operating inside hospitals). Data do not
include any information about nursing homes that are not certified.
NOTE: Facilities with CMS health inspection ratings of 1 or 2 stars were considered “below average”
Similarly, Virginia nursing homes with low staffing are more likely to receive low quality
ratings (FIGURE 6). CMS Quality Measures comprise 15 functional and health status
indicators, such as the percentage of residents with a pressure ulcer, with a urinary tract
infection, or who have experienced a fall. These are all considered measures of how well
nursing home staff are caring for residents’ physical and clinical health needs. (See
Appendix 2 for more information on CMS Quality Measures.)
8
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 6: Facilities in Virginia with lower staffing ratings are more likely to have low
quality ratings (2021)
SOURCE: Centers for Medicare & Medicaid Services Nursing Home Compare, “Provider Information.” Updated
August 1, 2021. Data includes all certified nursing facilities in Virginia, some of which are not licensed as nursing
homes by the Virginia Department of Health (e.g., long-term care units operating inside hospitals). Data do not
include any information about nursing homes that are not certified.
NOTE: Facilities with CMS quality measures ratings of 1 or 2 stars were considered “below average”
Nursing home staff and administrators indicate that low staffing leads to a “downward
spiral” in recruitment and retention that exacerbates existing staffing challenges and
adversely impacts quality of care. Low staffing not only impacts care quality for nursing
home residents, but also affects staff well-being and satisfaction. When staff are stretched
thin, there is a higher likelihood of burnout and turnover. This makes recruitment
increasingly difficult as nursing homes lose employees, putting greater pressure on
remaining staff and making recruitment and retention harder to manage.
Staffing issues are often the subject of complaints to the Virginia Office of the State Long-
Term Care Ombudsman (LTC Ombudsman). Virginia’s LTC Ombudsman receives and
investigates complaints from nursing home residents and family members. Complaints in
categories that are related to insufficient staffing consistently make up nearly half of total
complaints. These complaints are for issues that are associated with staffing, from slow
response time and insufficient assistance with daily tasks to gross neglect. (See Appendix 4
for more information about the complaint categories.)
9
Workforce Challenges in Virginia’s Nursing Homes
Research literature consistently finds a strong relationship between staffing and
quality
A large body of research over the last two decades has established that higher-staffed
nursing homes perform significantly better on care processes compared to lower-staffed
homes. Facilities with higher staffing tend to have lower mortality rates, fewer pressure
ulcers, fewer urinary tract infections, less weight loss and dehydration, and lower
hospitalizations among residents. In particular, increased RN hours per resident day are
associated with better clinical outcomes. Increased CNA hours and nurse aide retention
also improve quality and are believed to improve non-clinical quality such as resident
satisfaction.
Virginia is one of 16 states without a nursing home staffing requirement
Most states (34 states and the District of Columbia) have passed staffing mandates for
nursing homes (FIGURE 7). Other states’ staffing mandates are designed with varying
degrees of flexibility by using one or both of the following types of requirements:
• Minimum HPRD – nursing homes must deliver a certain number of licensed
nursing and/or direct care hours per resident day (e.g., West Virginia requires 2.25
nursing care HPRD)
• Minimum ratio – nursing homes must maintain a minimum ratio of licensed
nursing and/or direct care staff to residents based on facility census (e.g., Arkansas
requires 1 direct care staff per 6 resident, and 1 licensed nurse per 40 residents
during day shift)
• Both – nursing homes must maintain a minimum ratio of licensed nursing / direct
care staff, and deliver a certain number of licensed nursing / direct care hours per
resident day (e.g., Maryland requires 1 direct care staff per 15 residents, 1 RN per 99
residents, and 3.0 nursing care HPRD)
Of the states that have implemented some form of a staffing mandate, 18 have a minimum
HPRD, 8 have a minimum ratio, and 9 have both a minimum HPRD and a minimum ratio. No
states have staffing mandates that depend on average resident acuity, although NJ outlines
specific HPRD for specific types of care (e.g., oxygen therapy, intravenous care).
Federal requirements are still tied to resident acuity, so in all states that have mandated
staffing, nursing homes must meet state required thresholds and still staff appropriately for
their resident acuity. This means that in states that have set lower staffing mandates,
nursing homes may meet their state minimum but if their staffing levels do not provide the
level of care expected by CMS they will face federal actions.
10
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 7: Most state staffing mandates for nursing homes are based on minimum
direct care hours (2021)
SOURCE: Virginia Department of Health Office of Licensure and Certification. “Availability of Clinical Workforce for
Nursing Homes – Report to the General Assembly”, 2020.
CMS uses an acuity-based formula to determine the expected staffing level in nursing
homes. While this is not a formal staffing mandate, it sets an expected level of staff based on
the needs of the residents in each nursing home. Nursing home operators indicate that
staffing should be adjusted based on the varying needs of their residents. However, outside
of dedicated units for specific types of residents – dementia or individuals on ventilators –
research indicates that staffing numbers in nursing homes are primarily driven by the
number of residents, rather than level of need. Virginia’s nursing home data indicates that,
in line with national trends, facilities are not adjusting staffing significantly based on
resident acuity.
Virginia could require all nursing homes and certified nursing facilities to meet a
baseline staffing level
Establishing a staffing standard that sets a minimum or “floor,” for the number of staff in
facilities reduces the risk of poor quality of care. In addition to the strong relationship
between poorly staffed facilities in Virginia and low quality of care, research shows staffing
mandates have the strongest positive effect in facilities with the lowest staffing, as well as in
more competitive labor markets. In states that adopted staffing mandates, nursing homes in
the bottom quartile for staffing improved the most in reducing deficiencies and pressure
ulcers.
Staffing standards have also been shown to have a stronger effect on improving staffing
than directly increasing Medicaid reimbursement rates. While wages are important to staff,
they are not sufficient for retaining employees, particularly during periods of high stress.
The national average hourly rate for CNAs in nursing home has been increasing
dramatically over the last few years (up 7.13% in 2021), but so has turnover (up 51.38%).
11
Workforce Challenges in Virginia’s Nursing Homes
Better workloads reduce burnout and improve retention. Due to low supply and increased
demand for staff, there may be a natural wage increase as the labor market adjusts.
However, nursing home administrators indicate that a one-size-fits-all staffing requirement
would not be effective for the wide range of nursing homes across the state. Administrators
and nursing home leadership feel a staffing mandate would restrict their ability to flexibly
adjust staffing levels up or down based on their residents’ acuity and level of need. They
point out that CMS already regulates staffing, which is part of all regular federal surveys,
and additional state regulation could lead to unnecessarily increased oversight.
Administrators noted the possibility of some nursing homes having to shut down as a result
of being unable to meet a staffing standard.
A staffing floor would target underperforming facilities by setting a baseline
number of direct care hours for all nursing homes
Virginia could implement a staffing mandate using a required number of hours per resident
day (HPRD). If a flat, across-the-board standard is set, using a floor of 3.25 total HPRD
(including RN, LPN, and CNA hours) would target the lowest staffed and poorest
performing nursing homes. As part of this requirement for total hours, 0.4 HPRD of RN staff
time would mitigate the risk that nursing homes would limit RN hours to lower the cost of
increasing their total staff hours. CMS found that while resident acuity may impact the
amount of staff time required, its recommended threshold would still benefit the residents
of all facilities.
Based on August 2021 data from CMS, 26% of Virginia’s certified nursing facilities (74
facilities) reported less than 3.25 total HPRD. Similarly, 21% (59 facilities) reported less
than 0.4 RN HPRD. These are the only facilities that would need to increase their staffing to
meet a potential state requirement set at these levels. There were 33 facilities that would
not have met a baseline staffing standard for either total staffing or RN hours.
JCHC staff estimate that it would cost at least $28.1 million for all nursing homes to meet
this baseline staffing requirement with employee hours. This estimate is based on
comparing the average hours per resident day provided at each facility to the proposed
standard. It would require an estimated 818,377 additional hours of direct care staff time,
and 175,532 hours of RN time, to bring understaffed facilities up to the baseline. An
estimated $20.4 million of this cost would be attributed to Virginia’s Medicaid program,
based on the percentage of Medicaid residents in these facilities. Virginia receives a 50
percent match for its regular Medicaid program, so half of the costs for Medicaid recipients
would come from state funds, with the other half coming from federal funds. Facilities
would have to cover the additional staffing costs for their non-Medicaid residents, unless
the state provides additional funding or increases Medicaid reimbursements beyond the
estimated costs of meeting the standard. If nursing facilities are unable to bridge the
staffing shortfall with employee time and must turn to agency staff, estimated costs would
be higher.
12
Workforce Challenges in Virginia’s Nursing Homes
Using an across-the-board standard would be more transparent and easier to implement,
but would not account for resident acuity (TABLE 1). The Virginia Department of Health
(VDH) could oversee the new standard as part of its regular facility inspections, which
occur at least biennially, or develop a new oversight process. To provide some flexibility,
facilities could have room to meet an across-the-board standard on an interval determined
by the State Board of Health by regulation, such as a weekly or monthly basis, which would
allow for daily fluctuations as long as the interval averages meet the minimum hours
required.
TABLE 1: An across-the-board staffing requirement would be easier to implement but
would not account for resident acuity
Baseline Advantages Disadvantages
estimated cost
$28.1 million, • Establishes a “floor” for lowest • Does not account for resident
covered by: performing facilities acuity
• $10.2M federal • Transparent standard that is • Requires a new VDH oversight
Medicaid funds easy to understand process
• $10.2M state • Nursing home staff know what • Lack of consequences for failing
Medicaid funds kind of workload to expect to meet the standard
• $7.6M nursing
facility funds
OPTION 2: JCHC could introduce legislation to amend section § 32.1-127 of the Code of
Virginia to require nursing homes to provide at least 3.25 hours per resident day of total
direct patient care (total RN, LPN, CNA hours), including at least 0.4 hours per resident day
of RN care.
A staffing standard based on existing CMS expectations would adjust required
nursing hours based on resident acuity
Virginia could implement a staffing mandate requiring nursing homes’ reported total direct
care staffing and reported RN staffing to meet or exceed the expected case-mix total nurse
and case-mix RN staffing calculated by CMS based on resident acuity. This means the
standard would be a changing, customized target that differs for each facility, rather than a
uniform baseline number.
Based on August 2021 data from CMS, 21% of Virginia’s certified nursing facilities (60
facilities) failed to meet their CMS expected case-mix numbers based on their resident
acuity. When looking at RN hours, 25% of facilities (72 facilities) failed to meet their
expected case-mix hours. In August 2021, there were 35 facilities that did not meet their
expected case-mix numbers for either total staffing or RN hours.
JCHC staff estimate that it would cost at least a similar amount as an across-the-board
staffing standard, $30.1 million, for all nursing facilities to meet this acuity-based staffing
13
Workforce Challenges in Virginia’s Nursing Homes
requirement with employee hours. This estimate is based on comparing the reported hours
per resident day provided at each facility to the CMS expected hours. It would require an
estimated 274,500 additional hours of RN time and 728,705 additional hours of total direct
care staff time to bring all facilities up to the expected figures calculated by CMS. An
estimated $21.4 million would be attributed to Virginia’s Medicaid program, with half of
that portion coming from state funds. Facilities would have to cover the additional staffing
costs for their non-Medicaid residents, unless the state provides additional funding or
increases Medicaid reimbursements beyond the estimated costs of meeting the standard. If
nursing facilities are unable to bridge the staffing shortfall with employee time and must
turn to agency staff, estimated costs would be higher.
An acuity-based standard would give nursing homes the flexibility to adjust their staffing
based on case-mix, but it would be less transparent and require new oversight processes at
VDH (TABLE 2). Facilities submit staffing data to CMS on a quarterly basis, and CMS
releases Nursing Home Compare data monthly with each nursing home’s reported hours,
acuity-adjusted expected hours, and Staffing star rating. Using this staffing standard, VDH
could track on a quarterly basis if a facility’s reported hours fell short of its expected case-
mix hours.
TABLE 2: An acuity-based staffing requirement would require new oversight
processes but is more targeted to each nursing home’s resident mix
Baseline Advantages Disadvantages
estimated cost
$30.1 million, • Establishes a target for all • Staffing data is updated
covered by: nursing homes quarterly
• $10.7M federal • Requirement is specific to each • Case-mix hours are calculated
Medicaid funds nursing home’s resident acuity by CMS based on average
• $10.7M state expected care hours – it is less
Medicaid funds intuitive and more cumbersome
to calculate
• $8.7M nursing
facility funds • Requires a new VDH oversight
process
• More complicated to calculate
for nursing homes that are not
certified and do not receive a
case-mix HPRD from CMS
• Lack of consequences for failing
to meet the standard
OPTION 3: JCHC could introduce legislation to amend section § 32.1-127 of the Code of
Virginia to require nursing homes to provide at least the number of expected total direct
care hours and total RN hours that are calculated by CMS based on resident acuity in each
nursing home.
14
Workforce Challenges in Virginia’s Nursing Homes
Implementing a staffing standard will require effective regulation and oversight
Virginia would have to ensure effective oversight of any new staffing standard to realize the
expected benefit. It is currently very difficult to prove that a nursing home does not have
“adequate” staff under federal rules, and if a state standard is difficult to enforce, it will not
result in improved resident care. This would require checking to make sure each facility is
meeting the requirement, and then having productive enforcement mechanisms that help
struggling nursing homes raise their staffing levels.
Oversight of a staffing mandate would be the responsibility of VDH’s Office of Licensure and
Certification (OLC), which manages all nursing home licensure, state inspections, federal
surveys, and complaint investigations. OLC currently has no authority to issue fines on
nursing homes for violations of state law. If inspectors find a violation, OLC’s options are
only to issue a plan of correction, revoke or suspend a nursing home’s license, or restrict
new admissions. OLC indicated that this can make it difficult to enforce requirements
because they are caught between two extremes of doing very little or issuing severe
sanctions. The General Assembly would need to provide VDH with the authority to levy
additional, intermediate enforcement measures that would help provide effective oversight
of a staffing requirement, without being overly punitive to struggling nursing homes. OLC
would also require additional funding to support the administrative costs of creating,
implementing, and managing a new oversight process related to a staffing standard.
Funds to support a staffing requirement could come from the general fund or
other dedicated revenue
Increasing Medicaid reimbursements does not directly ensure staff receive higher wages –
to that end, many states have implemented wage pass-through measures that require
nursing homes to use any new Medicaid payment increases on direct care staff
compensation. This would only affect facilities with Medicaid residents and substantively
help facilities with a greater reliance on Medicaid payments.
Virginia could utilize a couple of different strategies to fund
the investments to support a nursing home staffing
Federal limitations for
mandate provider-specific taxes
Funds could come from the general fund or from dedicated • States can not guarantee
revenue sources that could be generated through provider providers that the taxes will
be returned to them unless
assessments or other taxes.
the amount returned to the
• Nursing home provider assessment. Implementing a provider is less than the
threshold defined by the
nursing home provider assessment would generate “hold harmless” rule –
additional state revenue that would then be matched with currently less than 6% of
federal funds, to pay for increased nursing home rates. revenues
Virginia is one of only six states that does not currently • Taxes cannot exceed 25% of
the state’s share of Medicaid
expenditures
15
Workforce Challenges in Virginia’s Nursing Homes
have a nursing home provider assessment (the others are Alaska, North Dakota,
South Dakota, South Carolina, and Texas). A nursing home provider assessment
would be levied on all nursing homes in Virginia, regardless of payer mix, but only
those that have Medicaid residents would see increased reimbursement (there are
currently 28 nursing homes in Virginia that do not take any Medicaid residents).
This approach is subject to federal requirements and would require CMS approval.
One primary advantage of this approach is that it does not require general fund
appropriations, and in general, the entities paying the assessment are the same
entities that benefit from the revenue generated.
DMAS would require additional funding to support the administrative costs of
creating, implementing, and managing a nursing home provider assessment.
OPTION 4: JCHC could introduce a budget amendment to include language in the
Appropriation Act directing the Department of Medical Assistance Services to develop a
proposal for a nursing home provider assessment that can be submitted to CMS for
approval. DMAS should work with appropriate stakeholders, including LeadingAge Virginia
and the Virginia Health Care Association, when developing the proposed assessment.
• Other revenue options. Another strategy that has been proposed is to reinstate
Virginia’s estate tax and use the revenue to increase nursing home reimbursement
rates. A bill during the 2021 General Assembly Regular Session (HB 2157, Delegate
Watts) would have reinstated an estate tax in Virginia for estates that meet certain
criteria, and designate revenues from the tax to be used for health care purposes,
including a proposed nursing home staffing mandate. Revenues were estimated to
reach $60 million per fiscal year.
Virginia has options for how it distributes additional funds to nursing homes
The General Assembly would have a choice between providing additional funds to help
nursing homes implement the staffing mandate, or expecting nursing home operators to
take on the costs.
• The General Assembly could implement the mandate and allow Medicaid
reimbursement rates, which are based on nursing home costs, to increase as a result.
This would take time, and because nursing homes would not receive increased
reimbursement until 1-2 years after hiring more staff, this approach could place
already-struggling nursing homes in a difficult financial situation.
• The General Assembly could provide increased reimbursements targeted to nursing
homes with insufficient staff or initial funding to help struggling facilities pay for
staff and meet the mandate.
• The General Assembly could adjust the current Medicaid reimbursement formula
overall to cover more costs. Currently, facilities who choose to take on increased
costs in order to invest more in their staff may not be fully reimbursed, depending
16
Workforce Challenges in Virginia’s Nursing Homes
on their peer group rate. While increasing reimbursement would not guarantee
facilities will use these increased reimbursements for staff, for those that do, the
additional funds could help bridge the gap until reimbursement rates can catch up to
the increased costs of meeting a staffing mandate.
Broader health care workforce shortage contributes to staffing
problems in nursing homes
While it is clear that adequate staffing is important to ensuring higher care quality in
nursing homes, there is broad agreement that there is a larger ongoing workforce shortage
that makes it more difficult to find staff. Implementing a staffing standard should be
supported by additional programs to bolster the health care workforce in order to ensure a
sufficient supply of direct care staff. This is especially important in light of demographic
trends that indicate that an increasing number of Virginians will need nursing home care in
the coming years. JCHC staff found that while there is a clear decline in workers, additional
factors such as culture, leadership, and workload influence
whether or not people enter or stay in the field.
Evidence of relationship between
Fewer LPNs and CNAs have entered the workforce staffing levels and COVID-19
outbreaks in nursing facilities is
each year since 2016 mixed. Different studies have found
The Department of Health Professions has documented rates of infection within facilities can
depend on:
decreasing numbers of CNAs and LPNs in Virginia over the
last five years, as an increasing number of individuals have • Rates of community
transmission
left the profession to retire or pursue other careers, and not
• Number of staff
enough new individuals have entered the profession. From
2016 to 2020, the number of CNAs licensed in VA decreased • Size of facility
by 4.3% from 61,302 to 58,669. In the same time period, In response to the high COVID-19
associated mortality rates in nursing
the number of LPNs licensed in Virginia decreased by 6.4% homes, a new federal mandate
from 31,102 in 2016 to 29,112 in 2020. While this affects announced in August 2021 requires
the entire health care industry, it is particularly problematic all nursing home workers to be
vaccinated. This may further shrink
for nursing homes, which rely mostly on CNAs and LPNs
the pool of potential employees.
rather than RNs for resident care.
The shrinking workforce is also less interested in working
in nursing homes. A survey of staff showed nursing homes are the least desired place of
employment for nurse aides. In interviews with JCHC staff, nursing home leadership often
mentioned there are many applicants who only turn to nursing homes as a stepping stone
to other health care settings, or when they cannot find employment elsewhere. Compared
to 2015, fewer CNAs now work in nursing homes and home health care establishments, and
more CNAs work in assisted living facilities and inpatient hospital departments. Turnover is
17
Workforce Challenges in Virginia’s Nursing Homes
higher for CNAs and LPNs than for RNs, and many nursing homes reported a consistent
churn of applicants and employees who regularly jump from facility to facility.
The COVID-19 pandemic continues to significantly exacerbate the labor shortage
Many nursing homes reported difficulty retaining staff through the COVID-19 pandemic, as
nursing staff resigned for various reasons, including infection, fear of infection, and child
care issues. While the uncertainty of the early months of the pandemic was a significant
challenge, the later easing of restrictions did not ease the staffing shortage. In interviews
with JCHC staff, all nursing home leadership reported continued difficulty with finding and
retaining staff since March 2021. Administrators attributed this to staff wanting to get away
from work to do more activities or travel to see family.
More recently, staff at some nursing homes resigned in response to vaccine mandates. One
facility JCHC staff visited reported that they lost 25 full-time employees (out of roughly 120
total staff) when they mandated the COVID-19 vaccine for all staff. Another reported that
they gained employees when a nearby nursing home instituted a vaccine mandate. A
federal vaccine mandate for all nursing homes that participate in Medicare or Medicaid is
expected to go into effect in the fall of 2021.
Virginia’s facilities have responded by offering various incentives to attract and retain
employees. These include signing bonuses, retention bonuses for employees who stay a
certain amount of time, bonuses for overtime shifts, flexibility in scheduling, and free meals.
Some states have also responded to the staffing shortages. For example, in April 2020, New
Hampshire established a temporary stabilization fund for long-term care workers, granting
weekly payments of $300 to full-time and $150 to part-time front-line health care workers
including nursing, housekeeping, and dietary staff.
Despite these incentives, most nursing homes are still not able to hire enough staff, and are
using additional strategies to provide enough hours of care. As of August 2021, 100% of
senior housing and skilled nursing operators across the nation who responded to a survey
by the National Investment Center for Seniors Housing & Care (NIC) reported using
overtime to backfill their staffing shortages (FIGURE 8). Most are also relying on staff from
outside staffing agencies to supplement their workforce needs.
18
Workforce Challenges in Virginia’s Nursing Homes
FIGURE 8: Nursing homes are primarily backfilling staffing shortages with overtime
hours (2021)
Ways organizations are backfilling staffing shortages
100%
84%
21%
Hiring professionals from Agency or temp staff Overtime hours
other industries
SOURCE: NIC Executive Survey Insights (Wave 31, July 12-August 8, 2021).
Administrators indicate that workforce challenges have been longstanding
All administrators with whom JCHC staff spoke noted staffing was already a problem before
COVID-19, and the pandemic has exacerbated the issue. In particular, many administrators
feel the enhanced unemployment benefits available as part
of COVID-19 relief efforts are disincentivizing people from
There are a variety of ongoing
working, given how low standard industry wages already efforts in Virginia to build the
are. The enhanced unemployment benefit ended September health care workforce:
2021. • Governor Northam’s Virginia
Healthcare Workforce Advisory
Nursing home administrators emphasized that while they Council chaired by Dr. Megan
are doing their best to recruit new employees to increase or Healy
maintain ideal staffing levels, the biggest barrier is a health • Governor Northam’s G3 Program
care workforce shortage. Fewer people are entering nursing • Authorization for Temporary
or becoming “career CNAs,” and those who do would rather Nurse Aides (TNA) practicing in
work for hospitals, private practices, or staffing agencies for long-term care facilities in
response to the COVID-19
better pay and benefits. Low Medicaid reimbursement
pandemic
means nursing home wages are not competitive, and staff
are being asked to do more work for less pay than they
could get somewhere else. Additionally, some administrators cited generational differences,
with increasing numbers of employees wanting to work flexible hours that best suit their
schedules rather than meeting the scheduling needs of the facility. Administrators also
19
Workforce Challenges in Virginia’s Nursing Homes
acknowledged the importance of stable leadership and good culture for recruiting and
keeping staff.
Staff indicate that multiple factors influence the shortage of direct care workers
Like administrators, staff noted understaffing in nursing homes has been a problem since
long before the COVID-19 pandemic. They touched on many of the same points made by the
administrators – pay is too low when there are much easier jobs for the same or better pay,
and good, stable leadership and strong teamwork make a huge difference in workplace
satisfaction. Some did feel there were generational differences in the workforce, with many
employees who had been in the field for a long time noting that newer employees had
different attitudes about the work and received inadequate training and preparation.
Additionally, staff emphasized the physical and emotional difficulty of managing high
resident numbers due to insufficient staff, and they cited high ratios of direct care staff to
residents (e.g., 1 CNA for 20 residents) as a primary reason for burnout.
Successful recruitment and retention of nursing facility staff depends on many
different factors
Nursing leadership and staff agreed that the most important factors to staff are wages,
benefits, training and opportunities for continued education and advancement, workplace
culture, and leadership. While good wages and benefits are important to staff, they are not
the primary driver. JCHC staff consistently heard that working in a direct care role for the
elderly is a mission-driven calling, and the staff who stay are those who truly care for their
residents and build relationships with their co-workers and residents.
A few staff from staffing agencies indicated that they would be more willing to work as full-
time employees of a nursing home if the pay was better and if the leadership were stable
and supportive. Many staff pointed to the importance of good leaders who could set a
culture of cooperation and teamwork, and were consistent about hearing staff needs and
respecting the work that they do.
There are several policy options that JCHC could consider to support nursing home
employees and bolster the workforce. Additional options were provided by the 2020 VDH
Ch. 932 Work Group report to the General Assembly on the availability of the clinical
workforce for nursing homes.
Financial support for direct care staff could be in the form of student loan
repayment
Virginia’s Mary Marshall Nursing Scholarship is available to undergraduates enrolled in
educational programs to become RNs, LPNs, and CNAs who commit to providing full-time
services in any health care setting in Virginia for at least one year. However, this program is
not targeted to the nursing home or broader long-term care workforce. Participants with
eligible educational loans may apply for scholarships of up to $2,000 per year.
20
Workforce Challenges in Virginia’s Nursing Homes
The Long-Term Facility Nursing Scholarship was
The Nurse Loan Repayment Program
established in 2016 but has not received any funding to
is a different program that tries to
award scholarships. This program provides the same incentivize RNs, LPNs, and CNAs to
$2,000 annual scholarship, with a maximum benefit of work in Virginia. Chapter 238 (2021
$8,000 over four years, but recipients must commit to Acts of Assembly, Special Session I)
added CNAs as eligible recipients to
working in a Virginia nursing facility. Minnesota has a this program. The program does not
similar program for RNs and LPNs who work at least two have any specific eligibility criteria
years in specific care settings, including nursing homes. related to nursing homes or long-
Program participants in Minnesota receive $6,000 a year, term care facilities.
up to a maximum of $24,000 over four years.
OPTION 5: JCHC could introduce a budget amendment to provide general fund
appropriations to the Long-Term Facility Nursing Scholarship program.
Other strategies could be used to incentivize workers to join or stay in the nursing home
direct care profession, particularly in the CNA role:
• Reduce or eliminate state income taxes for nursing home direct care workers; RNs,
LPNs, and CNAs who verify they were employed full-time in a nursing home for the
entire year could receive state income tax relief, with the incentive targeted to those
with greatest financial need.
• Pay stipends to help with child care or transportation expenses, similar to the
payments authorized under New Hampshire’s Long-Term Care Stabilization
Program.
Supporting nursing home leadership can help address workforce shortages
Virginia could support nursing homes in developing strong leadership and internal culture.
Nursing home staff shared that good leadership, culture, and opportunities for
advancement are important to workforce stability. When wages, benefits, and staffing
supports are lacking or strained, a good working environment can often be the deciding
factor for whether or not nursing home staff stay. Investing in programs to provide grants
for nursing homes to engage in staff capacity-building and culture may help facilities with
better retention. For example, the Virginia Gold Quality Improvement Program was a pilot
project that funded a two-year intervention to develop supportive work environments. The
program was funded with penalties collected from certified nursing homes as result of
federal violations and non-compliance. During the pilot program, turnover declined and
quality of care improved in most participating nursing homes. Facilities spent less than
$30,000 per year from the fund to implement their quality improvement projects.
OPTION 6: JCHC could introduce a budget amendment to include language in the
Appropriation Act directing the Department of Medical Assistance Services (DMAS) to
design and seek CMS approval for a quality improvement program addressing nursing
21
Workforce Challenges in Virginia’s Nursing Homes
home capacity-building with funding from the Civil Monetary Penalties Reinvestment Fund.
Program design could be based on the results of the Virginia Gold Quality Improvement
Program pilot project.
Additional strategies could incentivize and support better
staffing and care quality
Nursing home quality and staffing is dependent on a multitude of factors, and initiatives
with a narrow focus are unlikely to adequately address the challenges. In order to improve
Virginia’s nursing homes, it is important to address not only pure staffing numbers, but also
to pay attention to workforce issues, financing, and facility structure. To supplement the
policy options listed thus far, JCHC staff have compiled additional legislative options to
support nursing homes.
Incentivizing quality can improve care at facilities that already meet staffing
standards
While a staffing mandate acts as a floor for nursing homes
Legislators tasked DMAS in 2021 and is likely to have the greatest impact on low-achieving
with developing a Value-Based facilities, pay-for-performance programs can incentivize
Purchasing program for Virginia’s
better quality in nursing homes that are already meeting
nursing homes. The agency has
been convening a workgroup to the minimum. For example, a 2001 study by CMS found
design the initiative, which is that a strong minimum staffing level for nursing homes to
scheduled to go into effect in July provide consistent, timely care was 2.8 HPRD of CNA care.
2022.
While 85% of nursing homes in Virginia currently fall
Performance priorities:
short of this mark, making it an unrealistic staffing
• Maintenance of adequate requirement, using 2.8 HPRD or something similar as a
staffing levels
target – and providing incentives for nursing homes who
• Avoidance of negative care
meet it –would complement a baseline staffing standard.
events (e.g., hospital
admissions) Nursing homes that accept Medicare, also known as
Additional performance areas: skilled nursing facilities (SNFs), already participate in
• Preventive care Medicare pay-for-performance. CMS withholds 2% of
• Utilization of home and Medicare Part A fee-for-service payments to SNFs and
community-based services then distributes 60% of that pool as incentive payments.
• Other relevant domains of care Performance is measured based on risk-adjusted hospital
readmissions.
Other states have implemented pay-for-performance or value-based purchasing (VBP)
programs as a way to complement staffing minimums. For example, in Tennessee, there is a
2.0 HPRD staffing minimum for all direct care staff and 0.4 HPRD from a licensed nurse, but
nursing homes can receive additional payments based on additional performance measures
tied to staffing, resident satisfaction, resident quality of life, and clinical performance. In
22
Workforce Challenges in Virginia’s Nursing Homes
Georgia, there is also a 2.0 HPRD floor for all direct care staff, but nursing homes can
receive a 1% increase in rate if the nurse-to-resident ratio is above 2.5 and they agree to
participate in data collection for the program.
The General Assembly directed DMAS in 2021 to develop a VBP program for Virginia’s
nursing homes, and this project could be used to incentivize stronger staffing and quality in
nursing homes that are already meeting a baseline standard. This program prioritizes
adequate staffing levels and avoiding negative care events. The agency is convening a
workgroup to inform program design, and the program is scheduled to begin
implementation by July 2022. DMAS is looking at additional quality metrics and measures
for nursing home performance that may be added on in subsequent years.
Pay-for-performance initiatives are highly variable and need to be designed and
implemented effectively to improve nursing home quality. If incentive payments are too
small, the program may not effectively motivate changes in performance. Additionally, the
current directive does not include funding for a formal evaluation of DMAS’ nursing home
VBP program, which might include elements to assess whether the incentives are working
to increase staffing and quality, such as resident satisfaction surveys.
OPTION 7: JCHC could introduce a budget amendment to include language in the
Appropriation Act directing and funding the Department of Medical Assistance Services to
include a formal evaluation that includes assessing the program’s effectivess at increasing
staffing and quality.
Behavioral health needs are increasing, but not sufficiently addressed through
reimbursement rates
All of the administrators JCHC staff spoke with noted there has been a steady increase in
residents with behavioral health needs. In 2016, nearly half (45.3%) of nursing home
residents nationally were reported to have a dementia diagnosis, and a third (32%) had
other psychiatric conditions such as schizophrenia or mood disorders.
Residents with behavioral health needs require more attention and staff time but nursing
homes are not properly equipped to meet those needs. Administrators and staff shared that
when residents are having a behavioral episode and need to be watched closely to make
sure they do not harm themselves or other residents, a staff member that could have been
helping multiple residents must now spend the majority of their time with one resident.
This increases the workload of other staff on the floor. In nursing homes without locked
units, confused residents who try to leave the facility require additional attention. Staff
often lack the training to appropriately de-escalate or manage behavioral health episodes,
and do not have the capacity to spend extra time with agitated or combative residents. Low
staff turnover, adequate nurse staffing, and psychiatrically trained RNs and physicians allow
nursing homes to better provide behavioral health services to residents.
23
Workforce Challenges in Virginia’s Nursing Homes
Administrators noted that while resident behavioral health needs are captured in resident
acuity assessments, which are the primary metrics used for reimbursement and staffing,
the costs of meeting those needs are not adequately factored into reimbursement rates.
When setting reimbursement rates, DMAS considers a facility’s average resident acuity
(residents are classified into Relative Utilization Groups, or RUGS, based on their assessed
level of need), using data collected in the CMS Minimum Data Set (MDS). The MDS is
primarily focused on capturing diagnoses, medications, and physical needs, so a nursing
home may have higher acuity than documented when taking into account the residents who
require less physical care but more mental/behavioral health resources.
Developing a supplemental nursing home reimbursement rate for residents with specific
behavioral health needs could help nursing homes improve staffing and quality of care for
these residents. Enabling nursing homes to take on more of these residents could also
relieve some of the pressure on the struggling state psychiatric facilities that are facing
their own staffing shortages and have limited admissions. In Delaware, nursing homes
receive an additional 10% of the primary care rate component for residents “exhibiting
disruptive psychosocial behaviors on a frequent basis”. In Virginia, DMAS currently
provides similar, additional payments for nursing facility residents with traumatic brain
injury and ventilator dependent care, as well as increased rates for facilities where 80% of
the resident population has special diagnoses (e.g., cerebral palsy, multiple sclerosis).
Developing a reimbursement methodology to account for behavioral health needs will
require several steps. DMAS would need to identify the specific diagnoses that would
qualify for additional reimbursement, and then analyze the additional level of care required
to effectively manage these residents. That information can then be used to develop a
reimbursement rate that adequately reimburses nursing homes to care for these
individuals.
OPTION 8: JCHC could introduce a budget amendment to include language in the
Appropriation Act directing the Department of Medical Assistance Services (DMAS) to
develop a plan for an enhanced reimbursement rate to nursing homes for residents with
behavioral health diagnoses. The plan should include the diagnoses to be included, the
additional care and staff training required, and the estimated cost. The plan should be
submitted to the Joint Commission on Health Care, and the Chairs of the House
Appropriations and Senate Finance Committees by October 1, 2022.
Prioritizing other types of care would reduce need for nursing home workforce
over the long term
While there will always be a need for nursing home care, there is a growing emphasis on
making home and community-based services (HCBS) available to aging seniors in Virginia.
The JCHC study on strategies to support aging in place will have policy options to
strengthen HCBS.
24
Workforce Challenges in Virginia’s Nursing Homes
One strategy that would support both HCBS and nursing homes would be to reduce the
total number of nursing home beds in Virginia. A steady increase in the number of certified
beds in Virginia has reduced the occupancy rate of nursing homes over the last two decades
as the number of nursing facility residents has remained relatively stable (FIGURE 9).
Many nursing facilities have fixed expenses tied to the number of licensed beds they have,
regardless of occupancy, which means reimbursement sometimes covers excess capacity.
Smaller facilities with fewer beds tend to have higher overall star ratings than larger
nursing homes – and this is true for both for-profit and non-profit nursing homes. Large
nursing homes also have higher documented deficiencies, and with more employees and
residents, there is greater risk of infection and potential for larger outbreaks. This was
evident during the COVID-19 pandemic, when larger nursing homes had more COVID-19
deaths per licensed bed.
FIGURE 9: Occupancy in Virginia’s nursing facilities is declining as the number of
certified beds has increased without a corresponding increase in residents (2021)
Change in occupancy rate and certified beds, 2000-2017
-6% Occupancy Rate
Number of Certified beds +8%
-8% -6% -4% -2% 0% 2% 4% 6% 8% 10%
SOURCE: LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a
cooperative agreement with the Brown University School of Public Health. State data from 2000-2017.
Strategies to adjust occupancy rates could limit the amount of excess capacity
captured in Medicaid reimbursement rates
Incentivizing bed reductions could lead to cost savings for DMAS, because reimbursement
rates would not have to cover as much of the indirect and capital costs for empty beds.
Additionally, facilities would have the space and opportunity to convert older, double rooms
to single, private rooms. It is possible that a reduction in the availability of beds would
25
Workforce Challenges in Virginia’s Nursing Homes
result in fewer individuals being placed in nursing homes, requiring fewer staff. This may
be achieved through a variety of strategies:
• Bed buyback programs. Incentivizing nursing homes to reduce the number of beds
is another strategy that can be effective. Oregon enacted a short-term program in
2013 to reimburse nursing homes that voluntarily reduced their licensed bed
capacity. The goal was to increase efficiency and reduce costs for the state. Buy-back
was capped at $9.75 per resident day. As of 2021, Oregon’s current average nursing
home occupancy rate is 66% and most hospital discharges are to community
settings (e.g., home, assisted living, independent living) rather than to nursing
homes. Similarly, this year, Ohio has proposed a $50 million fund to buy back 5,000
bed licenses from nursing care providers at $10,000 each. This would require one-
time funding rather than ongoing funding.
• Expanded Medicaid reimbursement for private rooms. Currently, Medicaid
residents must meet certain criteria for DMAS to reimburse for a private room.
Private rooms are considered necessary when residents must be isolated from
others. This means nursing homes have little financial incentive to convert semi-
private rooms into private rooms. Adjusting the current reimbursement criteria may
make it easier for nursing homes to make this transition, reducing the number of
residents in the facility whether or not the number of beds a facility is licensed for
changes.
• Increased occupancy standards. Occupancy standards are occupancy thresholds
that are used for setting Medicaid reimbursement rates. Nursing homes must meet
this occupancy rate to receive their maximum reimbursement, discouraging an
excess of empty beds. The state Medicaid agency calculates a nursing home’s
reimbursement rate using their actual occupancy rate and the occupancy standard.
If the nursing home’s occupancy does not meet the standard, the nursing home
receives a lower reimbursement rate. Virginia currently has an occupancy standard
of 88%, but some states set higher thresholds. For example, Massachusetts’
occupancy standard is 96% - if a facility’s occupancy rate is lower than 96%, they
will not receive their maximum reimbursement. This encourages facilities to reduce
the number of beds or add more residents to ensure sufficient occupancy to make
efficient use of state funds. The occupancy standard only applies to capital costs for
nursing facilities in Virginia, meaning the impact of adjusting it up or down is
marginal.
Reducing the number of licensed beds in the state would potentially reduce expenses for
DMAS, but would also likely reduce revenue for the VDH Office of Licensure and
Certification (OLC). Nursing home licensure fees are a large source of OLC funds, and fees
are based on bed count.
26
APPENDICES – Workforce challenges in Virginia’s nursing homes
Appendix 1: Nursing homes in Virginia
While the terms ‘nursing home’, ‘nursing facility’, and ‘skilled nursing facility’ are often used
interchangeably, there are a few distinctions based on federal and state terminology.
Virginia refers to nursing homes that participate in Medicare and/or Medicaid as “certified
nursing facilities”. At a federal level, nursing facilities (NFs) generally refer to nursing
homes that provide long-term care and accept Medicaid, and skilled nursing facilities
(SNFs) refer to facilities where patients have short-term rehabilitative stays covered by
Medicare.
There are currently 285 nursing homes in Virginia, licensed by the Virginia Department of
Health (VDH) (FIGURE A1). Most are certified NF/SNFs that participate in both Medicare
and Medicaid. There are 10 nursing homes that only participate in Medicaid, 20 nursing
homes that only participate in Medicare. There are 32,573 certified beds for
Medicare/Medicaid patients across all certified nursing facilities in Virginia. There are eight
nursing homes that do not take any federal dollars, and are therefore not subject to any
federal reporting requirements or CMS ratings.
FIGURE A1: Different types of nursing facilities in Virginia
SOURCE: Nursing facility licensure data from the Virginia Department of Health.
An entire facility or just a portion of a facility can be licensed as a nursing home – for
example, in continuing care retirement communities (CCRC), which may be composed of
27
independent living, assisted living, and skilled nursing, only a portion of the CCRC is
licensed as a nursing home.
The list of Virginia nursing homes does not include long-term care units inside hospitals,
which are considered SNFs because they participate in Medicare, but are not state licensed
nursing homes as they operate under the licensed hospital. The list also does not include
two nursing homes owned and operated by the Virginia Department of Behavioral Health &
Development Services that are not licensed by VDH.
Nursing homes in Virginia range in capacity from 18 to 312 beds, with an average of 114
beds. The majority of Virginia’s nursing homes are for-profit (70%) and the remainder are
non-profit (28%) or government-owned (2%) facilities – this is in line with national trends.
28
Appendix 2: CMS five-star quality rating system
The Centers for Medicare & Medicaid Services (CMS) uses a rating system for all nursing
homes that participate in Medicare and/or Medicaid. Each participating facility receives an
overall rating between 1 and 5 stars, where 5-star nursing homes are considered to have
above-average quality and 1-star nursing homes are considered to have below-average
quality. The overall rating for each nursing home is based on its performance in three areas
– staffing, health inspections, and quality measures.
Staffing ratings
CMS grades all participating facilities based on the ratio of nursing staff to residents,
measured as hours per resident day (HPRD). The staffing rating is based on two measures -
total nursing hours (CNA + LPN + RN) and RN hours per resident day. Facilities submit
staffing data quarterly, and these reported hours are adjusted by CMS to account for
average resident acuity. Any nursing homes that report 7 days in a quarter without any RN
hours automatically receive a 1-star rating for staffing (TABLE A1).
TABLE A1: CMS criteria for staffing star ratings
SOURCE: CMS Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users’ Guide,
updated January 2021.
Health inspection ratings
CMS Health Inspection ratings are based on the number, scope, and severity of deficiencies
identified in a facility, as well as a weighted average of a facility’s three most recent health
inspections and complaint investigations. Ratings are assigned on a curve based on a
facility’s relative performance compared to other nursing homes in the state.
Assessments include facilities’ practices and policies regarding:
• Resident rights
• Medication management
• Skin care
29
• Quality of life
• Facility administration
• Environment
• Kitchen/food services
Deficiencies that are considered to put residents’ health or safety in “immediate jeopardy”
are weighted more heavily.
Ratings are based on a facility’s relative performance within the state to help control for
variation in survey management, state licensure, and Medicaid policy across the United
States. As a result, facilities are rated so that:
• Top 10% of scores = 5 Star rating
• Bottom 20% of scores = 1 Star rating
• 2, 3, 4 Stars are equally distributed across the middle 70% of facilities
Quality Measures ratings
Nursing homes receive three quality ratings - overall Quality Measures ratings, Long-Stay
Quality, and Short-Stay Quality - based on facility data from the Minimum Data Set (MDS)
and Medicare claims. In total, there are 15 function and health status indicators for Long-
Stay (residents who are in the nursing home for 100+ days) and Short-Stay residents that
measure facility performance (TABLE A2).
TABLE A2: Indicators used in CMS quality ratings
From MDS assessments From claims data
• Percentage of long-stay residents • Number of hospitalizations per
whose need for help with daily 1,000 long-stay resident days
activities has increased
• Number of outpatient emergency
• Percentage of long-stay residents department (ED) visits per 1,000
whose ability to move long-stay resident days
independently worsened
• Percentage of short-stay residents
• Percentage of long-stay high-risk who were re-hospitalized after a
residents with pressure ulcers nursing home admission
• Percentage of long-stay residents • Percentage of short-stay residents
who have or had a catheter inserted who have had an outpatient
and left in their bladder emergency department (ED) visit
30
• Percentage of long-stay residents • Rate of successful return to home
with a urinary tract infection and community from a SNF
• Percentage of long-stay residents
experiencing one or more falls with
major injury
• Percentage of long-stay residents
who got an antipsychotic
medication
• Percentage of short-stay residents
who improved in their ability to
move around on their own
• Percentage of SNF residents with
pressure ulcers/pressure injuries
that are new or worsened
• Percentage of short-stay residents
who got antipsychotic medication
for the first time
SOURCE: CMS Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users’ Guide,
updated January 2021.
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Appendix 3: Average nursing home acuity
The Brown University Center for Gerontology and Healthcare Research calculated average
acuity for each state’s nursing facilities based on the number of residents needing various
levels of activities of daily living (ADL) assistance and the number of residents receiving
special treatment. Data do not include Alaska or Washington, D.C. Data included all certified
nursing facilities, some of which are not licensed as nursing homes by the Virginia
Department of Health (e.g., long-term care units operating inside hospitals) (FIGURE A2).
32
FIGURE A2: Average acuity index for all states
MT 10.87
IA 10.95
MO 11.08
KS 11.08
ND 11.19
SD 11.24
WY 11.26
MN 11.27
OK 11.32
NE 11.42
NH 11.46
NM 11.64
CO 11.65
RI 11.66
VT 11.66
WI 11.7
IL 11.73
CT 11.84
UT 11.92
AR 11.93
ID 11.98
OR 12.02
MI 12.05
WA 12.06
MA 12.09
OH 12.11
AZ 12.19
PA 12.23
NJ 12.23
IN 12.25
LA 12.34
TX 12.34
MS 12.35
DE 12.41
NY 12.42
ME 12.43
KY 12.5
WV 12.51
FL 12.57
NV 12.61
VA 12.75
AL 12.76
MD 12.8
GA 12.83
NC 12.86
CA 12.86
SC 12.9
TN 13
HI 13.29
SOURCE: LTCFocus Public Use Data sponsored by the National Institute on Aging (P01 AG027296) through a
cooperative agreement with the Brown University School of Public Health. State data from 2018.
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Appendix 4: Complaints to the Virginia Office of the State
Long-Term Care Ombudsman
Almost half of the complaints received by the Virginia Office of the State Long-Term Care
Ombudsman are related to staffing – this includes complaints that are verified and not
verified (TABLE A3). Complaints might not be verified if the information in the complaint is
incorrect, or Ombudsmen were unable to determine what happened due to lack of a
corroborating witness or documented evidence. Regardless, Ombudsment follow up to
resolve all complaints to the extent possible to address meet residents’ concerns.
TABLE A3: Complaints submitted to the LTC Ombudsmen, by year
Major Complaint Category/Type Number of Complaints Received
2017 2018 2019 2020
Complaints Associated with Staffing
Abuse, gross neglect, exploitation 100 115 129 115
Care 901 990 1144 702
Dining and hydration 33 37 62 35
Facility policies, procedures and practices 97 164 202 115
(staffing)
Other Complaints 1188 1374 1694 1085
Access to Information
Admission, Transfer, Discharge, Eviction
Autonomy, Choice, Rights
Financial, Property
Activities, Community Integration and Social
services
Dietary
Environment
Facility policices, procedures and practices
(administrative oversight, fiscal management)
Total Complaints 2319 2680 3231 2052
Staffing-Related Complaints as Percent of Total 49% 49% 48% 47%
SOURCE: Data provided by the Virginia Office of the State Long-Term Care Ombudsman, Department of Aging and
Rehabilitative Services. Received July 2021.
34
Complaint categories align with those used by the National Ombudsman Reporting System.
Complaint code categories were changed in 2019, and reporting codes from previous years
may not reflect the categories listed in the table above.
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Appendix 5: Study Resolution
Impact of long-term care workforce needs on nursing facility care
Authorized by the Joint Commission on Healthcare on December 15, 2020
WHEREAS, more than 280 nursing facilities in Virginia serve more than 25,000 Virginians, who live
and receive care for their daily needs at those facilities; and
WHEREAS, Virginia’s nursing facilities employ direct care staff and licensed clinicians, such as
Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses who assist residents with
all aspects of daily living, including eating, dressing, and providing healthcare including proper
infection control protocols; and
WHEREAS, nursing facilities in Virginia are licensed by the Virginia Department of Health under
state and federal laws and regulations; and
WHEREAS, the Centers for Medicaid and Medicare services in 2018 downgraded 19 Virginia
nursing facilities on its quality rating system because they did not have enough registered nurses or
did not provide necessary staffing data; and
WHEREAS, the COVID-19 pandemic has highlighted the need for adequate staffing in Virginia’s
nursing facilities, to ensure proper resident care and minimize the risk of infection, now, therefore
be it
RESOLVED, by the Joint Commission on Health Care that staff be directed to study the workforces in
Virginia’s nursing facilities.
In conducting its study, staff shall (i) assess the extent to which there are staffing shortages for
nursing facilities in Virginia and understand the underlying causes of those staffing shortages; (ii)
evaluate the impact of staffing shortages on the quality of care provided in nursing facilities; (iii)
analyze whether these impacts are disproportionately impacting certain populations in Virginia
based on race, socioeconomic status, or other factors; (iv) assess whether Virginia’s current
licensing requirements and oversight are appropriately identifying and addressing quality of care
issues in nursing facilities; and (v) identify strategies to improve recruitment and retention of the
workforce necessary for Virginia’s nursing facilities.
The Joint Commission on Health Care shall make recommendations as necessary and review other
related issues as warranted.
In accordance with § 30-169.1 of the Code of Virginia, all agencies of the Commonwealth, including
the Virginia Department of Health, the Virginia Department for Aging and Rehabilitative Services,
the Virginia Department of Medical Assistance Services, local Area Agencies on Aging, and local
Departments of Social Services shall provide assistance, information, and data to the JCHC for this
study upon request. Assistance is also requested from the Virginia Health Care Association.
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JOINT COMMISSION ON HEALTH CARE
600 EAST MAIN STREET, SUITE 301
RICHMOND, VIRGINIA 23219
Mailing Address:
P. O. BOX 1322
RICHMOND, VIRGINIA 23218
804-786-5445
http://jchc.virginia.gov
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