Virginia health agencies outline reforms after sharp rise in nursing home complaints

RICHMOND — The Virginia Department of Health and the Department of Medical Assistance Services on Tuesday told the General Assembly subcommittee overseeing health and resources that both agencies are pursuing staffing, process and payment changes to address rising complaints and uneven quality in nursing facilities across the commonwealth.

Christopher Lindsey, chief operating officer for the Virginia Department of Health, said the Office of Licensure and Certification is “reimagining” nursing home oversight after complaints surged from about 730 in 2023 to 1,246 as of Sept. 5, 2024, and a projected 1,800 by year end. Lindsey said high-priority complaints — immediate and non‑immediate jeopardy cases — have shown a similar increase.

The spike in complaints has coincided with long gaps between federally mandated surveys. Lindsey said VDH’s goal is to meet the federal target of 15.9 months between surveys. He reported a recent improvement from a much longer interval to roughly 22.4 months as of June 2024, but said the department remained “a bit off the mark.”

Why it matters: Nursing facility residents are vulnerable and oversight lapses have direct consequences for safety and care. VDH and DMAS briefed lawmakers on concurrent strategies — VDH on inspections, complaints intake and inspector recruitment; DMAS on how Medicaid value-based payments reward facility performance.

What VDH is doing: Lindsey attributed survey delays to vacancies and said the Office of Licensure and Certification (OLC) had a roughly 42% vacancy rate across its divisions, with long-term care inspector positions especially strained. He told the committee that of 47 authorized long-term care inspector positions, 23 were vacant as of the Sept. 5 slide cited in his presentation. To address that, VDH has: - Created a Northern Virginia regional office to hire and pay at regional scales and deploy teams in Prince William County and other regions; - Added recruiters and a new HR business partner dedicated to OLC hiring; - Offered sign-on bonuses ($5,000) and up to 80 hours of upfront leave for outside hires; - Posted leadership and supervisory vacancies and said many positions attracted multiple applicants, with at least one MFI (medical facilities investigator) supervisor offer accepted the week of the briefing; - Established an interim leadership team including Jim Jenkins and Daryl Hellams and hired an executive adviser with hospital administration experience; - Planned a dedicated training manager, preceptor programs and partnerships with CMS and neighboring states to accelerate onboarding.

Lindsey said the office is redesigning complaint intake — now largely a single‑line, mixed phone/fax/email workflow — toward an automated online portal with triage, dashboards and dedicated complaint-investigation teams so MFIs can focus on surveys and investigations rather than intake. He also referenced Governor Youngkin’s Executive Order 52, which established an advisory work group and directed work on workforce capacity, training, process redesign and accountability; Lindsey said the group’s first meeting was scheduled for Sept. 15, 2025.

What DMAS said: Jeff Leonardi, director of long‑term services and supports at the Department of Medical Assistance Services, described the Nursing Facility Value-Based Purchasing (VBP) program that pays nursing facilities a portion of Medicaid funds based on six performance measures: two staffing measures (including a per‑resident staffing hours metric and daily RN hours) and four quality measures (pressure ulcers, urinary tract infections, hospitalizations and emergency department visits). He told the subcommittee that FY 2025 was the first year the full VBP pot — roughly $184–185 million — had to be earned by providers.

Leonardi said the Medicaid program now funds roughly $2 billion in base nursing facility payments and added that the state’s VBP design was producing some unintended outcomes: facilities with low star ratings could still earn some payments because performance on some measures was self‑reported or based on CMS datasets the agency uses (minimum data set, payroll‑based journal and claims). He said the data sources include facility-submitted minimum data set reports, payroll-based staffing reports and Medicare claims for hospital/ED utilization.

DMAS’s concerns and planned changes: Leonardi told lawmakers that VBP was maturing but needed methodological changes to avoid rewarding persistently low performers. He said DMAS is: - Considering revising metrics and weights and possibly sunsetting measures where statewide performance has improved; - Working to change how payments respond to year‑over‑year backsliding (so a facility that declines in performance does not continue to receive the same payment); - Exploring ways to incorporate licensure and inspection data from VDH into VBP eligibility or participation thresholds so facilities that fail to meet licensing standards cannot continue to receive incentive funds.

Lawmakers’ questions: Committee members pressed both agencies on timing and authority. Several asked why legislation enacted earlier had not yet produced implementable rules. Lindsey and Leonardi said recent statutes and rule packages were in process: VDH is drafting regulatory action to implement intermediate sanctions authorized by 2025 legislation and a licensing fee structure was scheduled for the Board of Health on Oct. 2. Lindsey said the regulations were “in process” and not yet effective.

Numbers and limits cited in testimony: - Nursing home complaints: 730 in 2023; 1,246 as of Sept. 5, 2024; projected 1,800 for 2024 year-end (Lindsey’s projection). - High‑priority complaints: 151 in 2024 baseline; 315 year to date; projected 426. - OLC vacancy rates: about 42% overall; long‑term care and acute care divisions with high vacancy percentages; 23 of 47 long‑term care inspector positions vacant (as cited by Lindsey). - Target federal survey interval: 15.9 months; reported interim interval: ~22.4 months. - FY 2025 VBP funding: roughly $184–185 million; total Medicaid base payments for nursing facility services cited at about $1.98 billion for FY 2025.

What they did not decide: The agencies did not announce new regulatory changes that are already finalized; they described steps under way, recruitment incentives, organizational redesign and pending regulatory filings. Multiple speakers — including lawmakers and DMAS staff — said CMS approval is required for methodological changes to the VBP program and that some reforms require rulemaking or federal signoff.

Context and next steps: Both agencies signaled intensive recruitment and training campaigns and closer coordination. Lindsey asked legislators to refer qualified applicants quickly for posted OLC leadership and inspector roles; Leonardi said DMAS will propose changes to VBP methodology in coming rule cycles and work with VDH to prevent incentive payments to facilities out of compliance with licensing standards.

Ending: The committee did not vote on any measure during the presentations. Lawmakers scheduled additional questions and follow‑up on how licensure, inspection outcomes and VBP incentives will be aligned going forward.