Aging and Disability Services Information for Professionals

AGING AND DISABILITY SERVICES ADMINISTRATION

Residential Care Services
Operational Principles and Procedures for Conditions on Licenses

Purpose

To implement statutes and regulations regarding the department’s authority to impose conditions on licenses in a consistent and uniform manner throughout the state subsequent to serious or repeated or uncorrected violations of statutes and regulations by licensees that require a restriction, limitation, or additional requirements of the Boarding Home to protect residents from harm.
Authority

RCW 74.39A.050(6), Long Term Care Services Options – Expansion.
RCW 18.20.190(1), (2), (4) Boarding Homes
Operational Principles
1. Condition(s) on a license may be recommended to facilitate correction of violations that are serious; or, are repeated or uncorrected in the past twenty-four months; and, a condition on the license of the home is necessary to protect residents” health and welfare.
2. Condition(s) may include, but are not limited to the following requirements: correction of violations within a specified time frame, training related to deficiencies cited, or, a limitation on the type of residents admitted to a home.
3. Conditions may also include the following requirements: a discharge of a specific resident; a change in license capacity; removal of specialty designation; prohibition on access to residents by a specific person; or demonstration by the licensee of its ability to meet financial obligation to continue to operate.
4. A condition is imposed as an additional requirement different from or more specific than the regulations.
5. Timeframes identified within this procedure to complete and process recommendations to impose a condition on a license are intended as a guide to staff and may be extended with management’s approval, except as otherwise specified in statute or regulation.
6. Licensees will be notified of a condition on the home’s license via personal service and/or certified mail receipt of a Statement of Deficiencies report and enforcement letter within ten (10) working days of completion of the last day of data collection. The enforcement letter must include, as a condition, the posting of the notification letter.
7. Licensees will be given an opportunity to question and/or clarify the Statement of Deficiencies report and/or the imposition of a condition on a license via the department’s informal dispute resolution process.
8. Licensees will be given an opportunity to contest imposition of a condition on a license via the administrative hearing process.
9. Imposition of a condition on the license is effective immediately upon written notification and is not postponed pending completion of informal dispute resolution and/or administrative hearing processes.
10. Recommendations to impose conditions on a license may be reviewed by Regional Administrators for any purpose including, but not limited to, quality assurance activities and information sharing within RCS’ management structure.
Procedure
1. Condition on License Recommendation
  1. RCS staff should:
    1. Document serious or repeated or uncorrected deficiency citations on a Statement of Deficiencies report within four (4) working days of completion of data collection.
    2. Initiate a recommendation for a condition on a license if deficiency citations are serious, or repeated, or uncorrected in the past twenty-four months, and, a condition on the license of the home is necessary to protect residents’ safety and welfare.
    3. Forward the original Statement of Deficiencies report, resident and staff (when warranted) sample list, and the recommendation to impose a condition on a license to the Field Manager within four (4) working days of completion of data collection. No Licensee History Memo is required.
    4. Meet and review the completed Statement of Deficiencies report with the Field Manager.
2. Management Review of Condition on License Recommendation(s)
  1. Field Managers should:
    1. Review, sign and send the approved Statement of Deficiencies report, resident and staff (when warranted) sample list and cover letter to the licensee via certified mail within six (6) working days of completion of data collection. The letter should include the notation that further enforcement action may be taken, criteria to complete an acceptable plan of correction, and the process by which the licensee may request an informal dispute resolution meeting.
    2. Verify:
      1. the deficiency citation is serious or repeated or uncorrected and necessitates a condition on the license.
      2. the recommended condition that will be imposed corresponds with the scope and severity of the deficiency citations.
      3. the correct legal requirement (WAC) is identified for each citation
    3. Accept the recommendation as submitted or modify or delete any portion. Field Managers will review changes in the recommendation to impose a condition with RCS staff.
    4. Notify the Regional Administrator and the Enforcement Officer when a condition on a license may be recommended.
    5. E-mail a copy of the Statement of Deficiencies report with the recommendation to impose a condition on a license to the Enforcement Officer within six working days of completion of data collection. Fax the signed front page. The e-mail must specify recommended condition and related requirements.
    6. Send a copy of the acceptable Plan of Correction to the Enforcement Officer when received from the licensee.
    7. Notify the Enforcement Officer of proposed changes in the Statement of Deficiencies report subsequent to completion of an informal dispute resolution meeting.
  2. Enforcement Officers should:
    1. Review the Statement of Deficiencies report to determine if a sufficient basis exists to approve the enforcement action recommended.
    2. Accept the recommendation or modify or delete any portion. Discuss the reason for the modification or deletion with the Field Manager who will review changes with RCS staff.
    3. Obtain the Assistant Director’s or the Assistant Director designee’s final approval and determination of the condition on a license to be imposed within ten (10) working days of completion of the last day of data collection.
    4. Notify the licensee of the imposition of a condition on a license within ten (10) working days of completion of data collection via personal service and/or certified mail receipt of the enforcement letter and a copy of the Statement of Deficiencies report. The letter should include the specific condition imposed, the effective date, and, information regarding the licensee’s informal dispute resolution and hearing rights and the condition that the enforcement letter must be posted in the facility/home.
    5. Direct Headquarters staff to send copies of the Statement of Deficiencies report and applicable enforcement letter(s) to the Field Manager and the Regional Administrator.
    6. Direct Headquarters support staff to notify applicable parties (i.e., AAG, HCS, DDD, MH, Ombudsman, etc…) of enforcement actions initiated, via e-mail distribution of applicable enforcement letter(s).
3. Removal of Condition(s) on a License
  1. Field Managers should:
    1. Notify the Regional Administrator and the Enforcement Officer via e-mail when the licensee has corrected the deficiencies that necessitated the conditions on the license and the conditions are no longer required to protect residents from harm.
  2. Enforcement Officers should:
    1. Accept the recommendation or modify or delete the recommendation to remove the condition on a license. The reason for the modification or deletion will be discussed with the Field Manager who will review changes with RCS staff.
    2. Obtain the Assistant Director’s or the Assistant Director designee’s final approval and determination of removal of the condition on a license
    3. Send a letter via certified mail to the licensee lifting the condition on the license.
    4. Direct Headquarters staff to send copies of the enforcement letter(s) to the Field Manager and the Regional Administrator.
    5. Direct Headquarters support staff to notify applicable parties (i.e., AAG, HCS, DDD, Ombudsman, etc…) of this action via e-mail distribution of the letter lifting the condition on the license.
4. Monitoring Visits During a ‘Condition On A License’ Order
  1. Field Managers may assign RCS staff to conduct routine monitoring visits of the home after the licensee has received a notice of a condition on the license.
  2. RCS staff should make observations, conduct interviews, review records and document their findings relating to the ongoing welfare and safety of residents in a memo to the Field Manager
  3. RCS staff should not make a determination of compliance with cited statutes and regulations during these visits.
  4. RCS staff should immediately notify the Field Manager if findings represent a diminished welfare and safety of residents since the last inspection and/or, represent imminent threat of harm to residents.
  5. If serious new issues are identified, RCS staff should call the new issue in as a complaint.
  6. Field Managers should immediately consult with the Enforcement Officer regarding findings obtained during monitoring visits if additional enforcement action may be warranted.
  7. The Enforcement Officer should coordinate with the Field Manager and the Assistant Attorney General to facilitate initiation of additional actions subsequent to a licensee’s ongoing failure or refusal to meet regulations that jeopardize the health and safety of residents or, that seriously limit the home’s capacity to provide care or services.
  8. Enforcement Officer should inform the Assistant Director or the Assistant Director’s designee of additional findings related to the licensee’s noncompliance and risks related to resident safety and welfare.
  9. The Assistant Director or the Assistant Director’s designee will determine additional enforcement action required.

Date 02-28-02

Patricia K. Lashway, Director

Residential Care Services