RICHMOND, Va. — A report delivered Thursday by the Virginia legislature's investigative arm, described by lawmakers as "sobering" and "disturbing", provided some answers as to why the state's public health agency has failed to complete timely nursing home inspections and complaint investigations.
Over the past several months, CBS 6 has investigated nursing home inspection delays after some Virginians expressed frustrations with the state's perceived lack of urgency and ability to address their complaints.
For example, Steve Lambert submitted a complaint to the Virginia Department of Health (VDH) in December 2023 regarding Westport Rehabilitation and Nursing Center in Henrico County where his brother Winfred Lambert was living.
Lambert alleged "horrifying" conditions at the facility after finding his brother exposed, half-dressed, and face-down in his bed. He said Winfred was unable to move himself due to muscle loss or speak for himself due to an intellectual disability. Lambert said he also discovered what he believed to be large pieces of someone else's dead skin covering Winfred's bed.
After CBS 6 questioned VDH about the status of Lambert's complaint, the agency finally opened an investigation eight months later in August 2024, seemingly beyond the timeline parameters established by the federal government for complaint investigations.
By the time VDH opened the case, Lambert's brother had died.
"They need a system in place to provide the proper oversight in a timely manner to ensure these vulnerable people are not harmed," Lambert said.
Then, there was Heather Tyler whose husband Earl lived in the same facility. She submitted a complaint to VDH in January 2024, also alleging poor conditions along with claims that Earl was left to sit in his own urine for hours and was found with explained marks on his body.
The day after CBS 6 aired Tyler's story in September 2024, she said she received a call from a VDH inspector indicating the agency had opened her complaint investigation eight months later.
“Get off your rear ends and do something about this. Something. Make people responsible. Make them accountable," Tyler said. "We’re failing miserably.”
Data from the Centers for Medicare and Medicaid Services (CMS), which sets requirements for state nursing home oversight, showed 68% of Virginia nursing homes were overdue for inspection, as of November 2024.
That's one of the worst performance metrics in the country, behind almost every other state.
Thursday's report from the Joint Legislative Audit and Review Commission (JLARC) on VDH painted a broad picture of an agency with significant inefficiencies, financial mismanagement, and poor hiring practices. Though these findings were applicable to the agency at large, the issues impacted certain areas more heavily than others including VDH's regulatory obligations.
In the VDH office that handles inspections, 71% of staff reported that they lacked the manpower to manage the workload.
The vacancy rate across the office sits at 23%, and the vacancy rate of long-term care medical facility inspectors was around 40% according to data provided by VDH in August.
JLARC's report concluded the staffing constraints rendered VDH "unable to investigate complaints and complete required federal inspections of nursing homes."
Aside from nursing home oversight efforts, JLARC also found:
- 99% of inpatient hospitals were not inspected in the last two years
- 91% of outpatient surgical hospitals were not inspected in the last two years
- 97% of home care organizations were not inspected in the last two years
CBS 6 approached VDH Commissioner Dr. Karen Shelton following Thursday's presentation.
“Are you able to comment on VDH’s inability to complete nursing home inspections?” reporter Tyler Layne asked.
“We have a prepared statement that we’ll send to all of you. Thank you," Shelton answered.
Though Shelter declined to take questions from reporters, her statement said she was committed to transparency and accountability.
"The challenges raised in this report were created across multiple years and they will take multiple years to fully correct. While my leadership team and I did not create these challenges, we are fully committed to solving them by putting in place the appropriate financial and operational controls and hiring the right leaders to drive change in the agency," Shelton said in a written statement.
Delegate Mark Sickles (D-Fairfax) chairs the commission. After receiving JLARC's report, he told CBS 6 he was "very concerned" when asked whether a lack of nursing home oversight could lead to worsening conditions for residents.
Sickles said the state needs to take a balanced approach to addressing conditions which he believes should include considering a direct care standard per day and increasing pay for healthcare workers.
“Everybody bears a little fault for things that aren’t up to standard, but for our seniors, we need to make sure that we up our game and Virginia is the best place to be if you have to be in a nursing home," Sickles said.
The state health department has previously pointed to stagnant funding from Congress over the past ten years. Federal lawmakers have not increased funding for CMS inspection efforts in a decade, despite a rise in nursing home complaints nationwide and despite requests for more money under President Trump's and President Biden's administrations.
While federal leaders believe funding may play a role, they don't believe money is the only issue at play.
“Why is Virginia so far out of whack from other states?” said U.S. Senator Tim Kaine (D-VA). "If it was just a federal funding issue, yes, you would see Virginia with a poor track record, but it would match what other states’ track records are, and I think this is obviously a significant issue for the state as well."
“I think it’s an embarrassment that Virginia is so behind other states in doing these inspections," U.S. Senator Mark Warner (D-VA) said. "I think the state needs to step up its game."
That said, both senators committed to advocating for more funding in the appropriations committee and addressing workforce challenges.
"As much as we've got to fund the inspectors, we also need to fund more folks into this workforce, and part of that means higher pay," Warner said.
CBS 6 is committed to sharing community voices on this important topic. Email your thoughts to the CBS 6 Newsroom.
📲: CONNECT WITH US
Facebook|Instagram|X|Threads|TikTok
EAT IT, VIRGINIA restaurant news and interviews
