Aging and Disability Services Information for Professionals

AGING AND DISABILITY SERVICES ADMINISTRATION

Residential Care Services

Operational Principles and Procedures For
Documentation of Deficiencies – BOARDING Home

PURPOSE
To apply statutes and regulations that give the Department of Social and Health Services’ the authority to provide written notice of violations subsequent to inspections conducted by Residential Care Services staff in Boarding Homes.
AUTHORITY
1. RCW 18.20.110 Boarding Homes (BH)
2. WAC 388-78-030 (3) (e) BH Minimum Licensing Requirements
3. RCW Chapter 43.20A Department of Social and Health Services
OPERATIONAL PRINCIPLES
1. A violation of statute or regulation must be documented.
  Types of documentation a violation of statute or regulation is recorded on:
  1. A Statement of Deficiencies (SOD) report is used to document violations of a statute and/or regulation following inspections conducted at a licensed Boarding Home.
  2. A cover letter is used to document violations of a statute and/or regulation that are first time violations, resulting in minimal or no harm to residents.
  3. In the BH setting, a cover letter is also used to document a violation meeting the following criteria: 1) the facility corrects the violation and the deficient practice is corrected to the satisfaction of the department prior to the exit; 2) the violation had not been cited in one of the two most recent preceding inspections or complaint investigations; and 3) the violation did not pose a significant risk of harm or actual harm to a resident. Those violations are defined as a consultation. (See Attachment’s #1, “Definition of Consultation”) and (Attachment #3, “Cover Letter for Inspections with Consultation Only”).
  4. A cover letter is used to document no violations or “Deficiency Free” and sent to the licensee (See Attachment #2, “Cover Letter for Inspections with No Deficiencies”).
  5. The BH tracking system contains the results of each inspection.
2. Deficiency citations should be recorded on the computerized reports (templates) following the Principles of Documentation.
3. Oral notice of the results of the inspection should be given to the licensee by RCS staff before the report is sent.
4. Licensees should be encouraged to start the plan for corrective action as soon as notified of the deficiencies cited.
5. Timeframes identified within the procedures for documenting deficient practice are intended as a guide to staff and may be extended with management’s approval, except as otherwise specified in statute or regulation.
6. SOD reports and cover letters documenting a deficient practice, should be completed by field staff and reviewed, and signed by the Field Manager.
7. SOD reports and/ or cover letters with documentation of a violation should be served in person and/or sent certified mail to the licensee within ten working days of completion of data collection to facilitate timely notice of violations to the licensee.
8. SOD reports and Licensee History Memos should be used by the Enforcement Officers to assist in making their recommendations for enforcement actions to the Assistant Director or the Assistant Director’s designee.
9. SOD reports and cover letters with documentation of a violation may be reviewed by Regional Administrators for any purpose including, but not limited to, quality assurance activities and information sharing within RCS’ management structure.
10. Positive resident comments should be documented in the cover letter, unless the inspection is due to a complaint investigation, follow up, monitoring visit, enforcement action or initial inspection.
PROCEDURE
1. On-Site Documentation of Inspection Process
  RCS field staff should:
  1. Document all pertinent findings including observations, interviews and record review information during an inspection;
  2. Critically analyze the findings to ensure the information is complete. Confirm the documentation answers pertinent questions regarding the failed (deficient) practices and related findings:
    1. Who?
    2. What?
    3. When?
    4. Where?
    5. How?
  3. Identify the regulation or statute that the failed practice violates;
  4. Determine the scope and severity of the failed (deficient) practice(s);
  5. Contact the Field Manager when questions arise related to the scope and/or severity of findings or immediate action is required; and
  6. Inform the licensee of deficient practice and findings at the exit.
2. Off-Site Documentation of Inspection Process
  RCS field staff should:
  1. Complete all data collection such as collateral interviews or further record review;
  2. Review all findings and documentation;
  3. Confirm analysis of deficiency citations and amend as needed;
  4. Consider any existing enforcement action from a previous inspection;
  5. Confer with the Field Manager if an enforcement action may be recommended, or if other questions arise; and
  6. Complete the following tasks or divide the following tasks with individual team members if more than one person conducted the inspection:
    1. Finalize and number the resident sample list;
    2. Finalize the staff sample list (use identifiers when needed);
    3. If a Statement of Deficiencies is required, complete comments on page one of the SOD; and
    4. Document all deficiency citations following the Principles of Documentation.
3. Documentation on all cover letters should include:
  1. Name of the licensee and home;
  2. The license number and address of the home;
  3. Inclusive dates and any information appropriate to weekend or night times:
    1. The start date is recorded as the first day onsite; and
    2. The end or completion date is recorded as the last day of data collection (may be different than the on-site date if further data is collected offsite).
  4. The term, “unannounced” is used for all types of inspection except an initial inspection.
  5. Type of inspection:
    1. Initial
    2. Licensing inspection
    3. Follow-up
    4. Complaint Investigation
    5. Monitoring visit
  6. Sample size and the home’s census (as of the start date);
  7. A brief summary of resident positive comments (omit if complaint investigation, follow up, monitoring visit, enforcement action or initial inspection is taking place);
  8. Team composition by names, titles (RN, RD, etc.) degrees (BSN, BSW, MS, MN, etc.) and job titles (Licensor, Complaint Investigator, etc.);
  9. Unit information including: office name, address, support staff telephone number; and
  10. IDR Program Manager’s name with contact information for Informal Dispute Resolution (IDR) process and licensee questions.
4. Documentation Specific to Results
  NO DEFICIENCIES
  RCS field staff should:
  1. Complete the cover letter as instructed in IV. Procedures C. Steps 1 - 9, using the template for“Inspections with No Deficiencies” (Attachment #2); and
  2. Include the type of inspection (licensing inspection or follow up).
    Note: No SOD is required
  RCS Field Managers should:
  1. Review and consult with field staff on inspection results;
  2. Consider any existing enforcement action from a previous inspection prior to approval of the consultation; and
  3. Approve and sign the cover letter.
  INITIAL VIOLATION WITH MINIMAL OR NO HARM TO RESIDENTS
  RCS field staff should:
  1. Complete the cover letter as instructed in IV. Procedures C. Steps 1 - 9, using the template for “Inspections with Consultation Only” (Attachment #3);
  2. Include the designated WAC(s) and/or RCW(s) the licensee is in violation of and bold the WAC number and title; and
  3. Write a brief (1 – 2 sentences) statement summarizing the deficient practice that is an initial violation with minimal or no harm to residents.
  4. Identify when the BH has corrected a citation to the departments satisfaction prior to the exit.
    Note: No SOD is required
  RCS Field Managers should:
  1. Review each cover letter and written consultation;
  2. Consult with field staff for clarification, amendments or additions;
  3. Consider any existing enforcement action from a previous inspection prior to approval of the consultation; and
  4. Approve and sign the cover letter.
  VIOLATIONS FOR CITATION (other than initial with minimal or no harm to residents)
  RCS field staff should:
  1. Complete the cover letter as instructed in IV. Procedures C. Steps 1 - 9, using the template for “Inspections with Citations” (Attachment #5); and
  2. Proceed to Statement of Deficiencies report IV. Procedures E. Steps 1 – 8.
  RCS Field Manager should:
  1. Review each written citation;
  2. Consult with field staff for clarification, amendments or additions;
  3. Consider any existing enforcement action from a previous inspection prior to approval of the SOD;
  4. Approve and sign the cover letter; and
  5. Direct RCS field staff/support staff to send the approved letter and SOD with sample list, and to the licensee via certified mail within six working days of completion of data collection.
  VIOLATIONS REQUIRING CONSULTATION AND CITATION
  RCS field staff should:
  1. Complete the cover letter as instructed in IV. Procedures C. Steps 1 - 9, using the template for “Inspections with Consultation and Citation” (Attachment #4);
  2. Follow the preceding procedures addressing documentation of an initial violation with minimal or no harm to residents for those violations that apply; and
  3. Follow the preceding procedures addressing documentation of violations for citation (other than initial with minimal or no harm to residents).
5. Documentation on the Statement of Deficiencies
  RCS field staff should
  1. Complete page one of the Statement of Deficiencies;
  2. Document all deficiency citations according to the Principles of Documentation. The deficiency citation must consist of:
    1. A regulatory reference (WAC and/or RCW);
    2. A statement of deficient practice (what the home did or did not do that violated the regulation or statute); and
    3. The relevant facts and findings (who, what, where, when and how).
  3. Cross-reference for citations in which findings have a direct cause and effect relationship to the deficient practices described in both citations. (Refer to Principles of Documentation– Principle #7);
  4. Consult with the Field Manager and Enforcement Officer to determine enforcement action recommendations when warranted;
  5. Identify if the violation is a repeat or uncorrected deficiencies (the same statute/regulation, subsection, and issue have been previously cited within specified time frames, and, are related to an enforcement action recommended);
  6. Documentation for repeated or uncorrected deficiencies related to an enforcement action recommendation should include at a minimum:
    1. Civil fines – 15 months (or the date of the last full inspection, whichever is greater);
    2. Conditions – 24 months;
    3. Stop Placement – 36 months;
    4. Revocation/Summary Suspension –36 months. Add a notation if additional compliance history is available upon request; and/or
    5. All other enforcement actions – 24 months.
  7. Refer to the Operational Principles and Procedures for Civil fines; Condition on Licenses; Stop Placement Orders Prohibiting Admissions; License Revocation; and Summary Suspension (MB #02-017) for more detailed information.
  8. Review, edit and finalize the SOD and appropriate cover letter; and
  9. Submit the completed SOD, resident and staff (when applicable) sample list, cover letter and licensee history memo (when applicable) to the Field Manager for approval within four working days of completion of data collection.
  Field Managers should:
  1. Review the completed SOD and cover letter with staff;
  2. Approve and sign cover letter and SOD;
  3. Confirm SOD report is sent to the licensee within 6 working days of completion of data collection; and
  4. Notify the enforcement officer if enforcement action is recommended and follow specific enforcement action procedures and timelines.
6. Enforcement Action
  Additional tasks are required for any deficiency citation resulting in any of the following:
  1. Civil Fines
  2. Conditions
  3. Stop Placement
  4. Revocation
  5. Summary Suspension
  RCS field staff should:
  1. Send a completed report to the Enforcement Officer with six (6) working days except for Summary Suspension, which must be submitted in 48 hours unless further direction is obtained from the Assistant Director; and
  2. Follow the Operational Principles and Procedures for each of the enforcement actions.
  For all enforcement actions except civil fines and conditions, a review of the SOD report is required prior to sending the report to the licensee. For Stop Placement, Revocation and Summary Suspension, RCS field staff should:
  1. Consult immediately with Field Manager;
  2. Document deficiencies that demonstrate serious harm or death to a resident or , that a serious threat to the life, health or safety of a resident exists including information about pertinent repeated or uncorrected deficiencies on a Statement of deficiencies;
  3. Complete Licensee History Memo;
  4. Forward all documentation – SOD, Licensee History Memo, and resident and staff sample list (when warranted) to the Enforcement Officer within two working days of completion of data collection; and
  5. Refer to Operational Principles and Procedures for Summary Suspension of a License, License Revocation, and Stop Placement Order Prohibiting Admissions for complete details of enforcement action procedures.
7. Amendment of Documentation of Deficiencies
  The documentation of deficiencies should be amended when new information is found after the report is sent to the licensee that should have been included in the report. This can occur in several situations including:
  1. Following review of Civil fines and Conditions by the Enforcement Officer (SOD is sent out prior to enforcement review);
  2. When staff discovers new information not related to existing examples included in the existing SOD report;
  3. Input from the licensee after they receive the SOD or deficiency documentation; or
  4. Following an IDR.
  When directed by the Field Manager, RCS field staff should:
  1. Incorporate the changes into the deficiency documentation, add “Amended”; the date of the amendment in the header; and italicize the new information;
  2. Forward the amended SOD to the Field Manager for review, signature and approval; and
  3. If the document is part of an enforcement action, forward to the Enforcement Officer for review and approval.
  The Enforcement Officer should:
  1. Obtain the Assistant Director’s or the Assistant Director designee’s approval and signature for an amended enforcement letter; and
  2. Coordinate delivery of the amended SOD report and amended/continued enforcement letter to the licensee via personal service and/or certified mail.

August 6, 2004

Patricia K. Lashway, Director
Residential Care Service