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AGING AND DISABILITY SERVICES ADMINISTRATION

Residential Care Services
Operational Principles and Procedures For Statement of Deficiencies Reports

  1. Purpose

    To implement statutes and regulations regarding the Department of Social and Health Services' (the department's) authority to provide written notice of violations subsequent to inspections conducted by Residential Care Services staff in Nursing Homes.

  2. Authority

    RCW Chapter 74.42 Nursing Home (NH) Resident Care Operating Standards
    RCW 18.51.091 Nursing Homes (NH)
    WAC 388-98-001(3); 388-98-830(1) NH Licensure Program Administration
    RCW Chapter 43.20A Department of Social and Health Services
    SOM - Appendix "P"; Survey Protocol for Long-Term Care Facilities (pg. 70)

  3. Operational Principles
    1. A Statement of Deficiencies (SOD) report will be utilized to document noncompliance with statutes and regulations subsequent to inspections conducted at the home of a licensee, an individual operating without a license, and/or, an applicant for whom denial of a license application is necessary.
    2. Noncompliance with statutes and regulations found during an applicant's pre-occupancy inspection will be documented on WAC sheet - "Nursing Home Survey Report".
    3. Deficiency citations should be written objectively and in a non-technical manner on a computerized SOD report. Deficiencies should not include advice, personal comments or directions given to the licensee or its staff.
    4. Deficiency citations will consist of a regulatory reference, a failed (deficient) practice statement and relevant findings related to the licensee's noncompliance with statutes or regulations. See Attachment #1, Definitions.
    5. Licensee noncompliance will be based on statutes and regulations. Interim guidelines, interpretive guidelines and references are intended for clarification and to provide information to help staff understand applicable legal authorities.
    6. Oral notice of findings during inspections should be given to the licensee by RCS staff when possible and appropriate. Licensees should begin initiating corrective action in response to deficiencies cited upon oral notice of findings during inspections.
    7. Timeframes identified within this procedure to complete and process SOD reports are intended as a guide to staff and may be extended with management's approval, except as otherwise specified in statute or regulation.
    8. SOD reports should be completed by field staff and reviewed, approved, signed and dated by the Field Manager.
    9. SOD reports and Licensee History Memos will be the basis upon which Enforcement Officers make their recommendations for enforcement actions to the Assistant Director or the Assistant Director's designee.
    10. SOD reports 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. On-Site Data Analysis/Documentation of Inspection Process
      1. RCS staff should:
        1. Document pertinent findings including observations, interviews and record review information obtained during an inspection.
        2. Critically analyze documented findings to verify completion of thorough data collection. Staff should confirm that the documentation answers pertinent questions (i.e., who, what, when, where, how and why) regarding the failed (deficient) practices and related findings.
        3. Determine the scope and severity of the failed (deficient) practice(s).
        4. Consult with the Field Manager when questions arise related to the scope and/or severity of findings. The Field Manager may consult further with the Enforcement Officer.
        5. Inform licensee of failed facility practice.
    2. Off-Site Documentation of Inspection Process
      1. RCS staff should:
        1. Review pertinent findings and confirm analysis of deficiency citations.
        2. Confer with the Field Manager if an enforcement action may be recommended, or if other questions arise.
        3. Appoint specific tasks to be completed by individual team members if more than one person completed the inspection. The tasks may include:
          1. finalizing the numbered resident sample list;
          2. finalizing the numbered staff sample list (only when needed to identify unsafe staff conduct to the licensee);
          3. completing comments on the first page of the SOD;
          4. designating F-tags and/or Code of Federal Regulations (CFRs) (when applicable) that will be cited in the report(s);
          5. documenting the failed (deficient) practice statements in relation to cited statutes and regulations;
          6. completing the appropriate cover letter; and,
          7. completing the licensee history memo if necessary.
        4. Complete page one comments including:
          1. The use of the term "unannounced" and the type of inspection. Identify the type of inspection as standard, follow-up, abbreviated (further identify by type as in complaint, pre-occupancy), extended, partial extended survey or monitoring visit.
          2. Inclusive dates and any information appropriate to weekend or night times. For the purpose of writing a SOD:
            1. The start date is the first day onsite.
            2. The end or completion date is the last day of data collection onsite.
          3. The name of the home and licensee.
          4. The address of the home.
          5. Sample size and the home's census (as of the start date). An example of a basic statement for the initial comment section could be: "__ of __ current residents and ___ former residents were selected for review."
          6. Team composition by names, titles (RN, RD, RS, etc.), degrees (BSN, BSW, MS, MN, etc.), and job titles (i.e., Surveyor, Complaint Investigator, etc.).
          7. Unit information (office name, address, support staff telephone number).
          8. Statement that "an enforcement action may be recommended, if warranted"
          9. A signature line designated as "Residential Care Services" and dateline for the Field Manager to sign and complete after SOD is reviewed and approved.
          10. Licensee or licensee's designee signature and date line.
          11. Comments will specify complaint number(s) when warranted.
          12. If no deficiencies are found in standard surveys, enter a statement "name of facility is in compliance with 42 CFR Part 483, Requirements for Skilled Nursing Facilities", complete a state licensure survey report and proceed to Step 12.
          13. If a licensed only facility, complete a state licensure survey report and proceed to Step 12.
        5. Select (i.e., highlight) applicable F-tag or CFR citations in numerical order.
          1. Review and verify that the selected CFR and/or F-tag is accurate and matches analyzed data compiled during the onsite inspection.
          2. The statement, "This requirement is not met as evidenced by:" will follow each selected deficiency citation.
        6. Document failed (deficient) practice statements for each deficiency citation selected. Failed practice statements will clearly state how the evidence was obtained, the extent of the failed practice and the consequences of the failed practice.
          Failed practice statements include:
          1. An introductory statement that:
            1. May begin with "Based on...".
            2. Identifies the sources of evidence to be included in subsequent findings (i.e., observations, interviews, and/or record reviews).
            3. Specifies the scope of the failed practice in relation to the sample selected.
            4. Documents identifiers designated either by number or letter (i.e., Resident #1, Staff #A).
            5. Specifies the action, error, and/or lack of action on the part of the licensee relative to the regulation and subsequent outcome, if any.
          2. A second statement (when applicable) that describes consequences of actual or potential harm to residents as a result of the licensee's failed practice as it relates to the cited regulation.
            1. Avoid conclusionary or speculative statements. Do not simply say, "because the home did not do X it caused Y" without corroborating evidence to support the statement.
            2. When warranted, note an immediate jeopardy, imminent threat or imminent danger of harm to residents was found and either corrected, or not corrected, prior to the end of the inspection.
          3. A third statement which states "Findings include:" if all examples of failed (deficient) practice are to be listed; or, "Findings include, but are not limited to:" if some, but not all examples are to be listed in the report.
        7. Document the negative findings related to the regulation cited and failed (deficient) practice written. Most severe examples should be listed first. Examples should:
          1. Answer pertinent questions including who, what, when, where, why and how.
          2. Be organized in a logical manner and relate to each aspect of the regulation with which the licensee failed to comply.
          3. Identify the source of evidence by which the negative finding was verified (i.e., observation, interview, record review).
          4. Use identifier numbers or letters to designate specific residents, staff, or other individuals who wish to remain anonymous, or, to protect individual confidentiality except to the licensee and to the department.
          5. Be gender neutral only to:
            1. refer to complainants; or,
            2. preserve resident anonymity (i.e., "he" or "she" would inadvertently identify the resident in correlation with other information in the report - for example, only one female resident who uses a wheelchair residing in the facility); or,
            3. protect residents, staff and/or individuals who wish to remain anonymous (i.e., "the resident", s/he, him/her). An appropriate method to convey the resident's or family member's wish to have the information remain confidential is to use a statement such as, "…residents who wished to remain anonymous, stated…".
          6. Describe relevant negative findings of the example written, in correlation with the licensee's failed practice and regulation cited. "Paint the picture" that clearly illustrates the failed practice.
          7. Use active rather than passive voice.
          8. Use past tense.
          9. Write in lay terminology. Intended audience is the licensee, the public, residents, family members, administrative law judge, etc…
          10. Use correct grammar and text style including the following:
            1. Spell out the word/phrase and include an abbreviation in parentheses the first time it is used in each citation. Since each citation must be able to stand alone, it will be necessary to do this for each citation, not once for the entire report.
            2. Information quoted must be exact. If an abbreviation is used in the quote, explain what it is in parentheses after the quote.
            3. Use capitalization with proper names/titles; when the phrase, "Resident #__" is used as a proper name; and, when abbreviations are used in place of a name or title (for example: "The nursing assistant (NA)…")
            4. Time - will be stated as regular clock time, not military or 24-hour clock time; use a.m. or p.m. consistently.
            5. Dates - use numbers to designate dates (i.e., 1/2/01).
            6. Dates of interviews - include the dates interviews were conducted with residents, staff and other individuals.
            7. Dates of record reviews - include the data entry date of information entered into the record that is critical to the explanation of the failed practice. (For example, "progress note dated___", "PT evaluations dated___"). Do not include the date the information was reviewed during the inspection.
            8. Only include diagnoses that are pertinent to the failed practice being discussed. When describing individuals with a condition, do not use the condition as an adjective (For example: The resident with diabetes, not the diabetic resident). Use caution when describing conditions that can identify a resident (For example: Amputation of Resident #1's lower left leg…).
            9. Use of medication names - determine whether it is necessary to name a specific medication. It is preferable to use a generic description (e.g., "blood pressure medication") or a generic term (e.g., aspirin). If the medication name is used, describe its purpose.
        8. Document violations that result in little or no negative outcome and minimal potential for harm for residents as specified in Steps #5, 6 and 7.
          In Nursing Homes, document A deficiencies on the HCFA "A" Form and incorporate the form into the SOD report.
        9. Reference (i.e., link) findings from one deficiency citation to another when findings have a direct cause and effect relationship to the deficient practices described in both citations. Each deficiency citation must contain sufficient evidence to demonstrate noncompliance with the specific statute or regulation identified in each citation.
        10. Document violations of Washington State statutes and regulations on Washington Administrative Code (WAC) Form 10-206 and/or 10-207, Nursing Home Survey Report.
        11. Determine enforcement action recommendations when warranted. Document repeated or uncorrected deficiencies if the same statute/regulation, subsection, and issue have been previously cited within specified time frames, and, are related to an enforcement action recommended. For example, at the end of an applicable F-tag deficiency citation, state, "This is a repeated or uncorrected deficiency cited on _____, _____, and _____."
          Repeated or uncorrected deficiencies related to an enforcement action recommendation should include at a minimum, documentation as follows:
          • Civil fines - 15 months (or the date of the last full inspection, whichever is greater);
          • Conditions - 24 months;
          • Stop Placement - 36 months;
          • Revocation/Summary Suspension - 36 months. Add a notation if additional compliance history is available upon request.
          • All other enforcement actions - 24 months.
        12. Meet to review, edit, and finalize the SOD and appropriate cover letter.
        13. 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.
    3. Regional Management Review of SOD Reports
      1. Field Managers should:
        1. When no enforcement action is recommended, sign and date the first page of the SOD and cover letter, and send the approved SOD report, resident and staff (when applicable) sample list, and cover letter to the licensee via certified mail within six working days of completion of data collection (consider any existing enforcement action from a previous survey action prior to sending letter).
          Direct unit support staff to send the completed SOD and cover letter to the regional Long-Term Care Ombudsman's office.
        2. When a civil fine or condition on a license is recommended, approve, sign and send the SOD report, resident and staff (when applicable) sample list and cover letter to the licensee via certified mail within six working days of completion of data collection.
          AND
          Complete and send civil fine packets to the Enforcement Officer within fifteen working days of completion of data collection.
          When a condition on a license is recommended, e-mail the SOD, resident and staff (when warranted) sample list to the Enforcement Officer within six (6) working days of completion of data collection. Specify recommended condition and related regulations on e-mail message.
        3. When denial of payment, in-service training, a directed plan of correction, stop placement of admissions, and/or license revocation are recommended, e-mail the approved SOD report, resident and staff (when applicable) sample list, and licensee history memo to the Enforcement Officer within six (6) working days of completion of data collection.
        4. When summary suspension of a license is recommended, e-mail the SOD 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 jeopardy of harm to residents has been removed.
    4. Headquarters Management Review of SOD Reports
      When review of a SOD report is required prior to distribution to the licensee (i.e., enforcement action recommendations excluding civil fines and conditions);
      1. Enforcement Officers should:
        1. Review the SOD report and Licensee History Memo within eight working days of completion of data collection to determine if a sufficient basis exists upon which the enforcement recommendation can be initiated.
        2. Coordinate completion of revision, review and approval of the SOD report and Licensee History Memo with the Field Manager.
        3. Obtain the Assistant Director's or Assistant Director designee's final approval and decision to initiate an enforcement action within ten working days of completion of data collection.
        4. Coordinate personal service of the SOD report, resident and staff (when warranted) sample list and enforcement letter (if completed) to the licensee within ten working days of completion of data collection when the department is initiating denial of payment, in-service training, a directed plan of correction, stop placement, termination, license revocation and/or summary suspension enforcement actions.
          AND/OR
        5. Send a copy of the SOD report, resident and staff (when warranted) sample list and, enforcement cover letter via certified mail to the licensee within ten working days of completion of data collection.
        6. Direct Headquarters support staff to send copies of the final SOD report with applicable enforcement letter(s) to the Field Manager and Regional Administrator.
        7. Direct Headquarters support staff to notify applicable parties (i.e., HCS, DDD, MH, Ombudsman, AAG, etc…) of enforcement actions initiated, via e-mail distribution of the applicable enforcement letter.
    5. Amended SOD Related to Enforcement Actions
      1. After the department has initiated an enforcement action, the SOD report should be amended when staff obtains new information related to examples within the existing report. When directed by the Field Manager, staff should incorporate this data into the SOD report, add amended, date, and new information and forward per the established procedure for Field Manager and Enforcement Officer review and approval.
        Enforcement Officers should obtain the Assistant Director's or the Assistant Director designee's approval and signature for an amended enforcement letter.
        Enforcement Officers should coordinate delivery of the amended SOD report and amended/continued enforcement letter to the licensee via personal service and/or certified mail.
      2. After the department has initiated an enforcement action, a new SOD report should be written when staff discovers new information not related to existing examples included in the existing SOD report. Staff should forward the new SOD report per the established procedure identified above for Field Manager and Enforcement Officer approval.
        Enforcement Officers should obtain the Assistant Director's or the Assistant Director designee's approval and signature for an amended enforcement letter incorporating the new SOD report into the enforcement action.
        Enforcement Officers should coordinate delivery of the new SOD report and amended enforcement letter to the licensee via personal service and/or certified mail.


Date: 11-21-03
Patricia K. Lashway, Director
Residential Care Services

ATTACHMENT #1:

DEFINITIONS

Deficiency: 1) a finding by the department of a violation of a) the requirements of chapters 18.51 and 74.42 RCW; b) the standards, rules, and regulations established under them; or, in the case of a Medicaid contractor, a finding of a violation of Medicaid requirements of Title XIX of the Social Security Act, as amended, and regulations promulgated thereunder; 2) a violation that results in negative outcome and actual or potential harm to residents; a failed (deficient) practice in relation to the statute or regulation cited that resulted in an actual or potential negative outcome(s).

Deficiency Citation: an entry made on the SOD report that consists of a legal reference, a deficient practice statement, and relevant findings. It includes:

Evidence: observation, interview, and/or record review data that substantiates the failure of the licensee to comply with the legal requirement.

Extent of the Failed (Deficient) Practice: the prevalence or frequency of a deficient practice.

Failed (Deficient) Practice: the action(s), error(s), or lack of action on the part of the licensee relative to a statute or regulation and, to the extent possible, the resulting outcome.

Finding: a generic term used to describe each discrete item of information observed or discovered during the inspection about practices of a licensee related to the specific statute or regulation cited. A finding is not deficient practice until all data is analyzed to determine failure of the home.

Home: a generic term used to describe a nursing home in the State of Washington.

Identifiers: number or letter designation of residents, staff or other individuals in the SOD report when warranted to preclude their identification except by the licensee or department staff.

Inspection: a generic term used to describe the process by which RCS staff evaluates licensee compliance with statutes and regulations. Inspections may be done onsite or by submission of requested documentation. Types of inspections include: pre-occupancy, initial, full standard, post revisit (follow-up), complaint investigation (abbreviated), extended, partial extended, and monitoring visits.

Licensee: a generic term used to describe individuals/entities/providers licensed to provide nursing home care in the State of Washington.

Outcome: an actual or potential result or consequence directly or indirectly related to failed or deficient practices of the licensee. Harm to residents that is not related to the home's failure is not an outcome for these processes.

Plan of Correction: a written statement by the licensee for each deficiency citation which should include six common elements:

Repeat deficiency: a violation of the same statute or regulation, subsection and issue that is repeated by a licensee within a specified time. The issue cited should be factually similar to the previous violation.

SOD: a written report that identifies violations of statutes and/or regulations, failed (deficient) practices and relevant findings found during inspections conducted at nursing homes. Types of Statements of Deficiencies include documents entitled: HCFA 2567L, WAC Form 10-206 or 10-207 Nursing Home [Survey] Report, or, SOD report.

Uncorrected deficiency: a deficiency citation that is not resolved by the licensee within a specified time and demonstrates ongoing noncompliance with the same statute/regulation, subsection, and issue.

Violation: 1) a deficiency; a finding by the department of a) the requirements of chapters 18.51 and 74.42 RCW; b) the standards, rules, and regulations established under them; or, in the case of a Medicaid contractor, a finding of a violation of Medicaid requirements of Title XIX of the Social Security Act, as amended, and regulations promulgated thereunder; 2) a violation that results in negative outcome and actual or potential harm to residents; a failed (deficient) practice in relation to the statute or regulation cited that resulted in an actual or potential negative outcome(s).

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