AGING AND DISABILITY SERVICES ADMINISTRATION

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Residential Care Services
Operational Principles and Procedures For Licensee History Memo

1. Purpose
   
   To implement regulations and guidelines regarding the Department of Social and Health Service's (the department's) authority to establish a basis upon which enforcement actions are taken in Boarding Home settings; and, to establish a method by which decisions regarding enforcement actions are documented.
   
   
2. Authority
   
   RCW Chapter 18.20 Boarding Homes (BH)
   WAC Chapter 388-78A Boarding Home Minimum Licensing Requirements
   
   
3. Operational Principles
   
   
   1. The basis upon which enforcement action recommendations are made, reviewed, and initiated will be documented on a Licensee History Memo and a Statement of Deficiencies report.
   2. Licensee History Memos should be completed for all enforcement action recommendations except recommendations to impose a civil fine or a condition on a license.
   3. Licensee information including current findings and significant compliance history related to the enforcement action recommended will be documented on a Licensee History Memo.
   4. Licensee History Memos will be completed, reviewed, and processed within specified time frames to facilitate adequate notice of imposition of enforcement remedies to the licensee.
   5. Timeframes identified within this procedure to complete and process Statement of Deficiencies reports are intended as a guide to staff and may be extended with management's approval, except as otherwise specified in statute or regulation.
   6. Licensee History Memos may be reviewed by Regional Administrators for any purpose including, but not limited to, quality assurance activities and information sharing within RCS' management structure.
      
      
4. Procedure
   1. Licensee History Memo Documentation Process
      1. RCS staff should:
         1. Document deficiency citations and provide the legal basis upon which an enforcement recommendation is warranted in a Statement of Deficiencies report.
         2. Confer with the Field Manager regarding possible recommendations for enforcement actions.
         3. Complete the Licensee History Memo per established format (See Attachment #1 and #2):
            1. Meet and review the completed Statement of Deficiencies report and Licensee History Memo with the Field Manager within four working days of completion of data collection when stop placement and/or license revocation is recommended.
               OR
            2. Meet and review the completed Statement of Deficiencies report and Licensee History Memo with the Field Manager within forty-eight hours of completion of data collection when summary suspension of a license is recommended, unless the Assistant Director or the Assistant Director's designee determines the immediate threat of harm to residents has been removed. When an initial letter of summary suspension is used, the licensee history memo is submitted with the amended Statement of Deficiencies.
   2. Regional Management Review of Licensee History Memo
      1. Field Managers should:
         1. Notify the Regional Administrator and the Enforcement Officer when an enforcement action may be recommended.
         2. Review, edit, and finalize the Statement of Deficiencies report and Licensee History Memo within six (6) working days of completion of data collection.
         3. E-mail the approved Statement of Deficiencies report, resident and staff, (when warranted) sample list, and Licensee History Memo to the Enforcement Officer within six working days of completion of data collection when stop placement and/or license revocation is recommended.
            OR
         4. When summary suspension of a license is recommended, e-mail the Statement of Deficiencies report, resident and staff (when warranted) sample list and Licensee History Memo to the Enforcement Officer within forty-eight hours unless the Assistant Director or the Assistant Director's designee determines the immediate threat of harm to residents has been removed. When an initial letter of summary suspension is used, the licensee history memo is sent with the amended Statement of Deficiencies.
   3. Headquarters Management Review of Licensee History Memo
      1. The Enforcement Officer will review the Statement of Deficiencies report and Licensee History Memo.
      2. The Enforcement Officer will forward the recommendation to the Assistant Director for action if the Enforcement Officer concurs that the recommendation is warranted and that submitted documents form the basis upon which action can be taken.
      3. The Assistant Director or the Assistant Director's designee will determine and authorize enforcement action based on the Enforcement Officer's recommendation.
         

Date: 02-28-02
Patricia K. Lashway, Director Date
Residential Care Services

ATTACHMENT #1: BH LICENSEE HISTORY MEMO FORMAT

LICENSEE HISTORY MEMO
Revised: November 21, 2001

TO: ________________, Field Manager
________________, Enforcement Officer

FROM: ________________, (Licensor, Investigator, Administrative Staff)
Region _____, Unit ______

DATE: ________________

SUBJECT: Name of Home
Administrator/Licensee name
License Number

OVERVIEW

• Address of home, including zip and county
• Mailing address, if different than facility address
• Date of licensure (most recent change of ownership)
• Type of contract (i.e. Medicare/Medicaid/DD/Mental Health/Hospital, etc)
• Number of licensed beds; and, current resident census
• Number of Medicaid residents (list only if Summary Suspension, License Revocation or Voluntary Closure in lieu of Revocation)

CURRENT FINDINGS

List and briefly summarize each significant regulation (i.e. pressure sores, resident funds, water supply, abuse, etc.) that forms the basis for the current enforcement recommendation(s). Include applicable RCWs and WACs.

HISTORY

Describe the home's compliance history including at a minimum: types and dates of inspections (including complaint investigations) conducted in the time frame specified below; repeated and/or uncorrected deficiencies that support the basis for the current recommendation; and, previous enforcement actions taken and brief description of issues.

Civil Fines - 15 months (or the date of the last full inspection, whichever is greater);
Conditions/In-service Training - 24 months;
Stop Placement - 36 months;
Revocation/Summary Suspension - date of initial licensing;
All other recommendations - 24 months.

When a nursing home, include scope and severity levels, and back in compliance dates unless the facility has had substandard care for the last three full surveys. When substandard X3, go back 3 years.

RECOMMENDATIONS

May include any one or more of the following (please delete those that do not apply):

• Initiate Stop Placement of AdmissionsRevocation of LicenseSummary Suspension of LicenseRefer to prosecutor's office, Fire Marshal, Nursing Commission, etc.

• Notify Home & Community Services, Division of Developmental Disabilities, Mental Health Division, Long Term Care Ombudsman Office, residents, and/or representatives.

• Notify Vendor Services to terminate contract (summary suspension only)

• Civil Fines (specify each pertinent WAC, amount recommended per instance and/or per day)*

• Condition on License (specify type)*

*IF a civil fine and/or condition on a license are recommended in conjunction with one of the above remedies, please note it on the Licensee History Memo. Civil fine packets may be submitted after submission of the Licensee History memo but should be sent for Enforcement Officer review within 15 working days of completion of data collection.

ATTACHMENT #2 Sample BH Memo

LICENSEE HISTORY MEMO
Revised: November 21, 2001

TO: Mae Erics, Field Manager
Curt Ramsey, Enforcement Officer

FROM: Margaret Reder, complaint investigator
Region 2, Unit C

DATE: 05/30/01

SUBJECT: Marion's Care Center
Marion Seller, Licensee
License # 2431A

OVERVIEW

Address: 110843 N. Pine Street, Yokum, Washington 99382, Marlend County
Mailing Address: same
Date of Licensure: 4/2/98
Type of Contract: Medicaid / DDD
Number of Beds: 48
Current Census: 37
Medicaid Residents: none

CURRENT FINDINGS

Complaint Investigation 05/1/01:
WAC XXX-XXX-XXX - General Management and Administration. (2) Licensee was not available to respond to resident needs and caregiver inquiries within a reasonable time frame.
WAC XXX-XXX-XXX - Additional License Requirements--Multiple Facility Providers (2) Licensee failed to ensure that the administrative plan adequately outlined who was responsible for oversight of resident care in the home and failed to adequately identify when/how to contact the licensee for resident needs. Repeat Violation from 06/21/99.

HISTORY

Complaint Investigation 03/02/01:
WAC XXX-XXX-XXX - Provision Of Services And Care. (4)(b) Licensee failed to ensure that resident services were delivered in a manner and environment that promoted safety. Resident #3 suffered a scratch on the ear on one occasion and a black eye on a different occasion while being dressed by a caregiver.

WAC XXX-XXX-XXX - Additional License Requirements - Multiple Facility Providers. (2)(a) The staffing plan for the home did not accurately reflect shifts worked by caregivers.

Annual Re-Inspection 08/11/00:
WAC XXX-XXX-XXX - Performance of Delegated Nursing Care Tasks. (1)(a) The licensee failed to ensure that 2 of 4 nurse delegation tasks were evaluated every 2 months.
WAC XXX-XXX-XXX - Resident Medications. (2)(a) The licensee failed to ensure that medications were kept locked.
WAC XXX-XXX-XXX - Resident Medications. (4)(b)(c) The licensee failed to ensure that medication organizers were labeled with name of resident and frequency of medication.
WAC XXX-XXX-XXX - Criminal History and Background Inquiry. (1)(a)(ii) The licensee failed to ensure that a volunteer caregiver had a criminal background inquiry.

RECOMMENDATIONS

Stop Placement of Admissions