SURVEY AND REGULATORY UPDATE
ASSISTED LIVING INSPECTION PROCESS: WHO CAN CONDUCT RESIDENT ASSESSMENTS IN ASSISTED LIVING?
Assisted living regulations are vague and thus cause confusion regarding the expectations surrounding who can conduct resident assessments. This article aims to provide clarification on this topic. 

Perhaps one of the most confusing aspects in the entirety of WAC 388-78A lies with the use of the word “assessment.” This word provokes thoughts of a nurse conducting a head-to-toe patient assessment or a medical doctor assessing a patient’s current ailment. While nursing assessments are necessary in assisted living, particularly for those residents needing some level of intermittent nursing services, the remainder of the assisted living resident assessment would be better termed “evaluation.” In fact, the vast majority of information gathered during an assessment is really evaluating the resident’s needs and preferences and requires very little by way of clinical expertise. Depending on the type of assessment, the assisted living provider might utilize staff with differing levels of education and experience. Let's take a look at the different types of "assessments" that may be required in assisted living:

PREADMISSION ASSESSMENT
The preadmission assessment is conducted before the resident moves in. This assessment must be completed by a “qualified assessor” whose education and experience are outlined in WAC 388-78A-2080 and includes a person with any of the following:
  • A master’s degree in social services, human services, behavioral sciences or an allied field and two years social service experience working with adults who have functional or cognitive disabilities.
  • A bachelor’s degree in social services, human services, behavioral sciences or an allied field and three years social service experience working with adults who have functional or cognitive disabilities.
  • A valid Washington state license to practice nursing.
  • This could be an LPN, RN, or ARNP
  • A state license to practice medicine.
  • Three years of successful experience acquired prior to September 1, 2004, assessing prospective and current assisted living facility residents in a setting licensed by a state agency for the care of vulnerable adults, such as a nursing home, assisted living facility, or adult family home, or a setting having a contract with a recognized social service agency for the provision of care to vulnerable adults, such as supported living.
  • Regardless of who performs your facility’s preadmission assessments, ensure documentation supports the individual’s qualifications.

FOURTEEN-DAY AND ONGOING ASSESSMENTS
All residents new to the facility must have a full assessment within 14 days of moving in and must address all aspects of WAC 388-78A-2090. Ongoing assessments are defined in WAC 388-78A-2100 and include:
  • Annual (or more often, based on the facility’s policies and procedures) full assessment as outlined in WAC 388-78A-2090
  • Focused area(s) of assessment based on:
  • A resident’s change in condition
  • Times when a resident’s negotiated service agreement no longer addresses the resident’s current needs and preferences
  • Times when a resident has an injury requiring the intervention of a practitioner

The person conducting the 14-day assessment as well as the ongoing assessments does not have to meet the stringent education and experience standards that are required for preadmission assessments. Regarding ongoing assessments, the regulation states:

“Ensure the staff person performing the on-going
assessments is qualified to perform them.”

Facility management could legally and feasibly train a staff person to conduct ongoing assessments to “ensure the staff person…is qualified to perform them.” It is suggested that any training provided to this individual(s) is documented, and any facility policy and procedure on the topic addresses who in the facility is qualified to perform ongoing assessments. Ideally this task is included in the individual’s job description.

NURSING ASSESSMENTS
Residents who need nursing services will need a nursing assessment. This assessment is focused on the resident’s condition(s) that warrant nursing care and can only be conducted by a registered nurse (RN). The Washington State nurse practice act outlines the differing roles and responsibilities of the RN and the LPN. An LPN can make observations, gather data, and provide relevant information as part of a nursing assessment, while the RN is responsible for conducting the nursing assessment.

WAC 388-78A-2310 captures what constitutes intermittent nursing services; any resident’s needs that fall into any or all of these categories would require a RN assessment, specific to these issues and/or resident conditions. Topics that warrant a RN’s assessment include:
  • Medication administration. This service is a complex one that involves times when a resident cannot perform the “final step” of medication self-administration or cannot accurately direct others to perform the task. Common medication administration provisions include times when a nurse must inject medications (vitamin B12 injections, for example) or spooning medications into a resident’s mouth when the resident is unaware s/he is receiving medications.
  • Administration of health treatments. This too is a vague term, and requires considerations of tasks that typically fall to licensed nurses such as prescribed wound care/wound dressing changes or indwelling urinary catheter changes.
  • Diabetic management, including whenever staff must perform blood glucose monitoring for a resident (piercing of the skin) and/or insulin injections. Individual facilities/companies may include other services under diabetic management in order to offer enhanced oversight of the condition, such as monitoring the extremities for wounds/skin breakdown, diabetic nail care, or even nursing oversight of any resident diagnosed with diabetes.
  • Nonroutine ostomy care. This includes changing the protective wafer around a stoma and observing/providing skin care to treat or minimize skin breakdown where the wafer is applied.
  • Tube feeding. 
  • Nurse delegation.

It is reasonable to assume that an assisted living facility has more than one staff person who can complete resident assessments. No matter the type of assessment conducted, the facility should have a system in place to ensure assessments are done timely and by the appropriately trained person(s).

If you have additional questions about assessments or other topics relevant to assisted living, please contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
SKILLED NURSING: RESIDENT RIGHTS - FOOD SERVICES
F812
Prior to the pandemic, across the nation, F812 (formerly F371) remained firmly in the top five frequently cited F-tags. With the ceasing of full surveys during the initial year of the pandemic and the current backlog of facility surveys by RCS, most skilled nursing facilities have not had their kitchen and food service department inspected in several years. Also, many dietary service departments have seen turnover of staff, and many have never been through an RCS inspection. Now is the time to revisit the food service requirements and prepare staff, not only to ensure compliance but to promote food safety.

According to F812, CFR 493.60 (i)(2)- the facility must store, prepare, distribute and serve food in accordance with professional standards for food service safety. Since food safety is an ongoing concern and can quickly escalate to resident harm and/or an IJ, the information below provides some focus and best practices to ensure compliance.

According to the Centers for Disease Control and Prevention (CDC), there are forty-eight million cases of foodborne illness per year in the United States. Of those cases, 3,000 result in death and 128,000 in hospitalizations. Foodborne illness can cause vomiting, diarrhea, fever, headache, chills, body aches, and stomach cramps. While not without risk for the general population, vulnerable adults residing in our facilities can quickly experience dehydration, weight loss, hospitalization, and potentially death. The primary things facilities need to focus on are:

  • Hand washing, hand washing, hand washing!
  • Implementing and consistently practicing a policy regarding ill food workers
  • Cooking food properly--know and monitor your food temperatures
  • Prevent cross-contamination from one food to another
  • Clean surfaces properly
  • NO BARE HAND CONTACT by any staff with ready-to-eat foods
  • Proper hot holding
  • Proper cold holding
  • Proper re-heating
  • Produce rinsing

Another key concept is ensuring there is always a Person in Charge (PIC) in the kitchen when staff are present. The PIC needs to know the risk factors and food code. He or she needs to be able to respond to surveyor questions regarding food safety and how the facility’s kitchen operates. The PIC also needs to be able to recognize the risk factors and hazards that contribute to foodborne illness and take appropriate action to prevent and correct actions that transmit foodborne illness. To effectively monitor food temperatures, the facility needs to obtain and consistently use a tip-sensitive thermometer. An example is the Comark PDT 300.

According to WAC 388-97-1100 Dietary Services, the facility must provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, as well as serve food in an attractive manner and at temperatures safe and acceptable to each resident. In addition, the facility must retain dated menus, dated records of foods received, a record of the number of meals served, and standardized recipes for at least three months for department review. All skilled nursing facilities must ensure that food service follows chapter 246-215 WAC. This is the same food code required for Washington restaurants and food service establishments. More information can be found on the Washington DOH Food Safety website.

If you have questions about the Washington Food Code, please contact Joe Graham, telephone (360) 236-3305, with the Department of Health. He is an excellent resource and expert when it comes to food safety. While DOH is not responsible for your inspections, nor will they direct RCS related to inspection processes, they are a resource to call outside of regulatory inspections to answer specific questions you may have about the food code.  If you have questions, please email Elena Madrid or call her at (800) 562-6170, extension 105.
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Tel (800) 562-6170