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36TH LEGISLATURE OF THE VIRGIN ISLANDS COMMITTEE ON CULTURE, YOUTH, AGING, SPORTS AND PARKS The Honorable Senator Angel Bolques, Jr Chair of Committee Testimony Presented By The Honorable Justa Encarnacion, RN, BSN, MBA/HCM Health Commissioner On “Aging with Dignity: Oversight of Nursing Homes and CMS Certification Readiness staffing, compliance, and senior care services throughout the Territory. ” VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 2 Good day, Honorable Senator Angel Bolques, Jr., Chairperson of the Committee on Culture, 1 Youth, Aging, Sports and Parks; Honorable Senator Carla J. Joseph, Vice Chair; distinguished 2 members of the Committee; other Senators present; and members of the listening and viewing 3 public. 4 I am Justa Encarnacion, Commissioner of Health. Joining me today are Dr. Nicole Craigwell- 5 Syms Assistant Commissioner of Health from St. Thomas, and Raphael Joseph, Risk Manager. 6 Chairman Bolques and members of the Committee, thank you for the opportunity to provide 7 testimony on “Aging with Dignity: Oversight of Nursing Homes and CMS Certification 8 Readiness—Staffing, Compliance, and Senior Care Services Throughout the Territory.” We 9 appreciate this important discussion and along with your continued commitment to ensuring that 10 older adults in the Virgin Islands receive safe, high-quality, and dignified care. 11 The Virgin Islands Department of Health is committed to strengthening oversight of long-term 12 care facilities while assisting providers in preparing certification under the Centers for Medicare 13 & Medicaid Services (CMS). Our goal is to establish a consistent regulatory framework that 14 protects residents, supports providers, and positions eligible facilities to participate in the 15 Medicare and Medicaid programs that is based upon the CMS Conditions of Participation. 16 CMS certification is a critical component of quality assurance and regulatory oversight. Through 17 compliance with federal Conditions of Participation, facilities demonstrate adherence to 18 nationally recognized standards for resident safety, clinical care, and operational excellence. 19 Certification also allows facilities to participate in Medicare and Medicaid reimbursement 20 programs, providing an essential source of financial sustainability for long-term care providers. 21 Recognizing the importance of this effort, the Department convened a CMS Readiness 22 Stakeholder Meeting on February 17, 2026, with healthcare leaders and industry partners from 23 across the Territory. Among the attendees were Policy Advisor Clint Ferris, Human Services, 24 Virgin Islands House Authority, and Nana’s Baby Home. The purpose of the meeting was to 25 introduce the CMS certification process, review federal requirements, identify current gaps, and 26 begin developing a coordinated strategy to support providers pursuing certification. 27 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 3 Discussion centered on the CMS Conditions of Participation, which establishes health and safety 1 standards for a variety of healthcare providers, including hospitals, federally qualified health 2 centers, home health agencies, hospices, rehabilitation facilities, and long-term care providers 3 such as nursing homes and other residential care settings. 4 Following the stakeholder meeting, facility assessments were conducted at three of the primary 5 long-term care facilities, (Herbert Grigg Home for the Aged, on St. Croix, Queen Louise Home 6 for the Aged and Eldra Schulterbrandt Residential Facility, on St. Thomas) 7 The assessments determined that neither facility was adequately prepared to successfully 8 undergo a Centers for Medicare & Medicaid Services (CMS) Initial Certification Survey. 9 Significant operational, clinical, and life-safety deficiencies were identified, indicating that the 10 facilities were not consistently maintaining the level of survey readiness required under federal 11 regulations. 12 Examples of deficiencies observed during the assessments included incomplete and inconsistent 13 resident clinical documentation; gaps in care planning and care plan implementation; medication 14 management and medication storage concerns; inadequate infection prevention and control 15 practices; insufficient staff training and competency validation; lack of quality assurance and 16 performance improvement processes; and challenges with maintaining required staffing 17 oversight and accountability. In addition, life-safety concerns were identified, including 18 deficiencies related to emergency preparedness, fire safety systems, environmental maintenance, 19 and documentation required to demonstrate ongoing compliance with federal standards. 20 The findings indicate that these issues are not isolated incidents but reflect broader organizational 21 and systemic challenges. As such, corrective actions focused solely on individual deficiencies are 22 unlikely to achieve sustained compliance. Rather, the facilities will require a comprehensive 23 systems-based approach that strengthens governance, leadership oversight, staff accountability, 24 clinical operations, quality management, and life-safety compliance. Coordinated corrective 25 actions across these domains will be essential to achieving and maintaining CMS certification 26 standards and ensuring the delivery of safe, high-quality care to residents. 27 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 4 As the Territory's healthcare regulatory authority, the Department of Health is responsible for 1 licensing healthcare facilities, establishing regulatory standards, monitoring compliance, and 2 promoting continuous quality improvement throughout the Virgin Islands. For long-term care 3 providers, CMS certification requires compliance with the federal Conditions of Participation 4 outlined in 42 CFR Part 483, as well as applicable Life Safety Code and Emergency 5 Preparedness requirements. Upon certification, facilities receive a CMS Certification Number 6 (CCN), allowing them to participate in the Medicare and Medicaid programs. 7 Achieving these standards will require strategic investments in three key areas: 8 • Workforce Capacity – Recruiting, training, and retaining qualified healthcare 9 professionals, including registered nurses, licensed practical nurses, certified nursing 10 assistants, and other essential staff. 11 • Infrastructure and Life Safety – Modernizing facilities to meet federal life safety 12 requirements, improve emergency preparedness, and strengthen resilience against natural 13 disasters and other hazards common to the Territory. 14 • Operational Excellence – Enhancing clinical documentation, quality assurance, 15 infection prevention, medication management, and governance systems necessary to 16 maintain compliance and deliver consistent, high-quality resident care. 17 The Territory continues to experience shortages of registered nurses, licensed practical nurses, 18 and certified nursing assistants. Competition from travel staffing agencies, workforce turnover, 19 housing limitations, and rising living costs continue to affect recruitment and retention. 20 To strengthen oversight while supporting providers seeking Medicare participation, the 21 Department has adopted a two-step approach. 22 First, the Department is advancing the development of a comprehensive territorial regulatory 23 framework for nursing homes, assisted living facilities, residential care facilities, senior centers, 24 and other supportive residential settings. This framework will establish clear and consistent 25 standards governing facility licensure, staffing requirements, resident rights and protections, 26 medication management, admissions and discharges, quality assurance and performance 27 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 5 improvement, inspection and enforcement activities, incident reporting, and administrative 1 accountability. By establishing these minimum standards, the Territory will create a strong 2 foundation for safe, quality, and consistent care across all long-term care settings, regardless of a 3 facility's participation in the Medicare program. 4 Second, the Department will offer technical assistance and regulatory guidance to facilities that 5 elect to pursue CMS certification. While territorial licensure confirms compliance with local 6 requirements, CMS certification is a distinct federal process with separate eligibility and 7 compliance standards. To obtain certification, facilities must qualify under an approved Medicare 8 or Medicaid provider category, demonstrate compliance with applicable federal regulations, 9 successfully complete required surveys or accreditation reviews, and maintain ongoing 10 adherence to CMS requirements. 11 This dual approach enables the Department to strengthen territorial oversight of long-term care 12 services while providing facilities with a defined and achievable pathway toward federal 13 certification. By aligning local regulatory standards with best practices and supporting providers 14 throughout the certification process, the Territory can enhance the quality of care available to 15 residents while expanding opportunities for participation in federal healthcare programs. 16 Success will be measured through objective indicators that demonstrate both regulatory 17 compliance and sustained operational improvement. Key performance measures will include the 18 successful completion of CMS Initial Certification Surveys, reductions in identified deficiencies, 19 and the ability of facilities to maintain survey readiness on an ongoing basis rather than through 20 short-term corrective efforts. 21 Additional measures of success will include improvements in clinical quality outcomes, 22 compliance with infection prevention and control standards, staff training and competency 23 completion rates, workforce recruitment and retention metrics, implementation of effective 24 quality assurance and performance improvement programs, and resolution of life-safety and 25 environmental compliance issues. Progress will also be evaluated through routine mock surveys, 26 corrective action monitoring, leadership accountability reviews, and ongoing assessments of 27 resident safety, quality of care, and resident satisfaction. 28 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 6 Ultimately, success will be achieved when the facilities demonstrate the capacity to consistently 1 meet federal standards, sustain compliance over time, and provide safe, high-quality care that 2 supports the health, dignity, and well-being of all residents. 3 Under this approach, territorial licensure serves as the foundation for lawful operation within the 4 Virgin Islands, while CMS certification provides a pathway for eligible facilities to participate in 5 Medicare and receive reimbursement for covered services. By implementing this two-step 6 framework, the Department can establish immediate and consistent territorial oversight while 7 preserving a clear and attainable pathway for facilities seeking to meet federal standards and 8 participate in the Medicare program. 9 Achieving CMS certification requires more than regulatory compliance. It requires strengthening 10 clinical and operational systems, building workforce capacity, upgrading infrastructure, and 11 preparing facilities for the CMS survey process. To accomplish this, the Department proposes a 12 coordinated, territory-wide implementation strategy over approximately 12 to 18 months, 13 encompassing regulatory alignment, workforce development, infrastructure improvements, 14 quality assurance systems, and survey readiness activities. 15 Herbert Grigg Home for the Aged and Queen Louise Home for the Aged were historically 16 established to provide long-term residential and nursing care for elderly residents, adding to the 17 fact that the territory currently has limited nursing-facility capacity, makes them the closest fit to 18 the federal definition of a nursing facility. DHS has acknowledged that redevelopment efforts at 19 both facilities are intended to restore CMS-certified nursing facility capacity. 20 CMS certification applies to facilities that provide 24-hour nursing services, medical 21 oversight, rehabilitation services, and comprehensive resident care in accordance with 22 federal nursing home regulations. Many assisted-living facilities, adult residential facilities, and 23 senior housing communities do not meet this level of care and therefore would need significant 24 changes before becoming eligible for certification. 25 Costs: The estimated project cost for CMS certification with existing building structures ranges 26 from approximately $8.5 million to $14. Million per facility, reflecting national CMS readiness 27 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 7 benchmarks adjusted for island construction costs, supply chain limitations, and workforce 1 shortages. This estimate includes regulatory readiness, policies, training, mock surveys, 2 consulting, quality systems, clinical, staffing and operational improvements. 3 Legislative support will be essential to the success of this initiative. Specifically, the 4 Department will require support to appropriate the resources necessary for long-term care 5 modernization, authorize regulatory updates that align territorial requirements with CMS 6 standards and nationally recognized best practices, strengthen investments in workforce 7 development and facility infrastructure, and establish transparency and reporting requirements 8 that promote accountability and public confidence in the long-term care system. 9 The Department supports incorporating the CMS Conditions of Participation, along with other 10 applicable CMS standards, into the Virgin Islands Code as the minimum standards governing 11 nursing facilities, long-term care facilities, and homes for the aged. While many providers 12 currently look to these federal requirements as best-practice guidance, codifying them in 13 territorial law will create a clear, uniform, and enforceable regulatory framework applicable to all 14 facilities operating under the Department's jurisdiction. 15 The adoption of these nationally recognized standards will provide the foundation for the 16 development of Virgin Islands-specific regulations, inspection protocols, compliance tools, and 17 enforcement mechanisms that are both responsive to local needs and aligned with established 18 federal expectations. This approach will strengthen regulatory oversight, enhance consistency in 19 enforcement, and provide facilities with clear operational and compliance expectations. 20 By establishing CMS standards as the minimum benchmark for care, the Territory can advance 21 quality, safety, and accountability across the long-term care continuum while creating a stronger 22 pathway for facilities seeking future federal certification. Most importantly, it will help ensure 23 that all residents—regardless of a facility's Medicare or Medicaid participation status—receive 24 safe, dignified, person-centered, and high-quality care. 25 Chairperson Bolques and members of the Committee, Thank you for your continued leadership 26 and commitment to improving long-term care services throughout the Virgin Islands. The 27 VI DOH Testimony on Oversight of Nursing Homes/CMS readiness July 17th 2026 8 initiatives discussed today extend beyond achieving regulatory compliance; they reflect our 1 collective responsibility to ensure that our seniors receive safe, dignified, and high-quality care 2 in environments that promote their health, independence, and well-being. 3 Achieving this vision will require strategic investments, strong administrative oversight, and 4 thoughtful legislative support. By working collaboratively to strengthen clinical operations, 5 modernize infrastructure, expand workforce capacity, and enhance accountability systems, we 6 can build a long-term care network that is resilient, transparent, financially sustainable, and 7 capable of consistently meeting federal standards and community expectations. 8 The Department of Health remains committed to partnering with the Legislature, the Department 9 of Human Services, healthcare providers, and community stakeholders to advance these efforts 10 and support facilities in their pursuit of CMS certification and long-term operational excellence. 11 Together, we can create a stronger continuum of care that protects our most vulnerable residents 12 and ensures that older adults throughout the Virgin Islands receive the quality of care and support 13 they deserve. 14 CMS certification means improved quality of care, access to federal funding, strengthening our 15 health delivery system, and better health outcomes for the people of this Territory. 16 Thank you for the opportunity to provide this testimony. I am available to answer any questions 17 the Committee may have. 18