I appreciate the Virginia Department of Health's efforts to strengthen accountability within nursing facilities and to provide a structured framework for the use of administrative sanctions. Residents deserve safe, high-quality care, and providers that repeatedly fail to meet their obligations should be subject to appropriate oversight and enforcement. Strong accountability measures are important not only for resident protection but also for maintaining public confidence in long-term care services. The proposed guidance appropriately recognizes that serious threats to resident health and safety, abuse, neglect, and persistent noncompliance may warrant significant intervention.

At the same time, I encourage the Department to ensure that the sanctioning process remains transparent, predictable, and proportionate to the nature and severity of the underlying violation. The success of any enforcement framework should ultimately be judged not by the number of sanctions imposed, but by whether it drives meaningful and sustained improvements in resident outcomes, quality of care, and quality of life.

The guidance appropriately states that sanction decisions are fact-specific and that citation counts alone do not automatically result in sanctions. However, many of the proposed review triggers rely heavily upon patterns of citations, repeat deficiencies, or broader concepts such as "systemic failure," "persistent noncompliance," and "management failure." While these concepts are important, they are also inherently subjective. Without additional explanation or objective criteria, facilities may find it difficult to understand how sanction decisions will be made or how similar circumstances will be evaluated consistently across different facilities, survey teams, or future administrations.

For this reason, I encourage VDH to provide additional guidance regarding how sanction decisions will be evaluated. For example:

• What factors carry the greatest weight when determining whether sanctions should be pursued?
• How are actual resident harm, potential harm, severity, scope, duration, and corrective actions weighed against each other?
• What evidence demonstrates a "systemic failure" versus an isolated failure?
• How does VDH distinguish between a facility that is unwilling to achieve compliance and a facility that is actively working toward correction but facing operational challenges?

Greater clarity around these questions would improve consistency, strengthen confidence in the enforcement process, and reduce the likelihood of uneven application.

I also encourage VDH to place primary emphasis on resident impact and demonstrated risk rather than citation counts alone. While repeated citations can indicate legitimate compliance concerns, citation volume does not always correlate directly with resident harm or poor outcomes. In practice, multiple citations may stem from a single operational issue, documentation deficiency, or survey interpretation. Likewise, facilities may receive repeat citations while simultaneously demonstrating meaningful improvement in resident outcomes and quality indicators.

An enforcement framework that focuses primarily on the existence of citations rather than the severity of resident impact may unintentionally incentivize regulatory compliance activities that improve survey performance without necessarily improving resident care. The most effective sanctioning system is one that remains focused on actual resident outcomes, resident safety, and sustained quality improvement.

Another area deserving consideration is the potential impact of admission restrictions and admission prohibitions. The guidance identifies both restrictions on admissions and complete admission bans as potential sanctions. While these tools may be appropriate in certain circumstances, they can also create unintended consequences that extend beyond the facility itself.

Many nursing facilities operate within broader healthcare systems that depend upon timely access to post-acute and long-term care services. When admissions are restricted, hospitals may experience discharge delays, patients may remain hospitalized longer than medically necessary, families may have fewer placement options, and access to care may become limited within a region. In some markets, particularly those experiencing workforce shortages or limited bed availability, admission restrictions imposed on one facility can create operational strain throughout the continuum of care.

Additionally, admission restrictions can reduce revenue at precisely the time when facilities may need additional resources to implement corrective actions, recruit staff, provide training, or invest in quality improvement initiatives. While sanctions should create accountability, they should also be structured in a manner that supports the achievement of compliance rather than unintentionally undermining a facility's ability to correct identified deficiencies.

I also recommend that VDH consider recognizing and rewarding evidence of good-faith corrective efforts. Facilities that promptly identify problems, self-report issues when appropriate, implement corrective action plans, invest resources to address deficiencies, and demonstrate measurable improvement should be viewed differently than organizations that repeatedly disregard regulatory requirements. A sanctioning framework that recognizes transparency and good-faith improvement efforts can encourage providers to engage proactively with regulators rather than fear that every identified problem will inevitably escalate into more severe enforcement action.

Another consideration is the rapidly evolving workforce environment affecting long-term care providers across the Commonwealth. Facilities continue to face significant challenges related to staffing shortages, workforce recruitment, rising labor costs, and increasing resident acuity. These realities should not excuse poor care or noncompliance. However, they do provide important context when evaluating whether a deficiency reflects an isolated operational challenge or a broader organizational failure. Enforcement decisions should consider both the deficiency itself and the facility's demonstrated efforts to recruit staff, stabilize operations, and maintain resident safety under challenging conditions.

I am also concerned about the long-term implications of broad discretionary standards. The current guidance may be implemented thoughtfully and appropriately under today's leadership. However, guidance documents often remain in effect for many years and may ultimately be interpreted by different administrators, survey managers, and reviewers. Broad standards that rely heavily on subjective judgment can gradually evolve over time in ways that were not originally intended. More objective criteria and clearer decision-making standards would help ensure consistency for residents, providers, and regulators regardless of future changes in leadership or enforcement philosophy.

Finally, I support the Department's stated goal of protecting residents and addressing serious noncompliance. Facilities that expose residents to abuse, neglect, significant harm, or serious threats to health and safety should be subject to decisive and appropriate action. However, sanctions should remain proportional, evidence-based, and focused on achieving sustained improvements in quality of care. Enforcement works best when it is viewed as fair, predictable, and consistently applied. A framework rooted in transparency, objective standards, resident outcomes, and meaningful opportunities for correction will better serve both residents and the long-term care providers entrusted with their care.

Thank you for the opportunity to provide comments on this proposed guidance document and for your continued efforts to promote resident safety and quality care throughout the Commonwealth.