SURVEY AND REGULATORY UPDATE
ASSISTED LIVING INSPECTION PROCESS: FAMILY ASSISTANCE WITH MEDICATIONS AND TREATMENT
The list of top citations over the past quarter shows family assistance with medications or treatments peaking at #2, the highest this WAC section has been since its inception in 2004. This article is designed to assist in determining where the facility’s system may need strengthening, to avoid citation.

Family assistance with medications and treatments is an optional service; the assisted living facility or company must notify prospective and current residents and their legal representatives regarding whether the assisted living permits family assistance or administration of medications and/or treatments and, if so, the extent of any conditions or limitations of that service. Mention of this service, and any limitations or conditions associated with it, must be included on the facility’s disclosure form.

If the facility currently offers this service and is interested in transitioning to staff-only provision of medications and treatments, written notice must be provided and time allowed to move away from family management of meds and/or treatments, per WAC 388-78A-2710. An updated version of the facility’s disclosure form must be shared with all current residents and legal surrogate decision makers, if applicable, with signature indicating receipt of the document.

WHAT IS INCLUDED IN FAMILY ASSISTANCE?
Perhaps one of the first issues that creates confusion and subsequent citations is the fact that family assistance or administration of medications or treatments involves much more than simply families performing a specific task for the resident. WAC 388-78A-2290, section (1) highlights all that is included in this provision:

An assisted living facility may permit a resident's family member to administer medications or treatments or to provide medication or treatment assistance, including obtaining medications or treatment supplies, to the resident.

In essence, family assistance, then, includes times when any or all the following services are conducted by family:
  • Ordering medications or treatments for a resident
  • Picking up medications or treatment supplies from the pharmacy or other location
  • Delivering medications or treatment supplies to the resident
  • Setting up medication organizers for a resident to self-administer
  • Helping a resident to self-administer medications or perform treatments
  • Administering medications
  • Administering treatments

If your facility allows family assistance with medications or treatments, you will need to ensure there is a distinct family plan in place that highlights every aspect of the WAC. 

When pieces of the plan are missing, citations can result. It is highly recommended, then, that someone at the facility assists the family in completing the family plan, to ensure all parts of the plan are filled in.

The plan, in its entirety, should offer clear details on who will be doing the medication or treatment management, what specifically this person will be doing, and when the service(s) will occur. This plan provides information to facility staff, so they can step in and follow up if the family does not implement all or part of the plan.

In reviewing WAC 388-78A-2290, a family plan must include:
  • By name, the family member who will provide the medication or treatment assistance or administration.
  • Be sure the individual’s name is included here, not “daughter” or “son” or similar. This provides clear information for staff in the event this person does not perform his/her duties as outlined in the plan.
  • PRIMARY PLAN: A description of the medication or treatment assistance or administration the family member will provide.
  • Be sure details are included. For example, if family is picking up medications from the pharmacy and delivering them – which pharmacy does the resident use? How often does the family order and pick up medications? Are there specific days of the week/month when this occurs? The more detail included in the plan, the better. Imagine a caregiver or med aide (or another family member) needing to step in and fulfill this role – will the information in this plan offer them enough information to fill in?
  • ALTERNATE PLAN: If the family member named in the plan is unable to fulfill his or her duties as specified in the primary plan.
  • This alternate plan may include a replacement family member, or the facility can have a policy outlining standard alternate plan for any time a primary plan cannot be implemented. For example, a standard alternate plan may be that the facility staff will regain all aspects of resident medication management.
  • An emergency contact person and telephone number in the event facility staff observes a change in the resident’s overall functioning or condition that may relate to medication or treatment plans.
  • The entire family plan must be signed and dated by the following individuals:
  • The resident (if able)
  • The resident's representative (if any)
  • The resident’s family member responsible for implementing the plan
  • A representative of the assisted living community

While the WAC does not outline how often this plan needs to be updated, it should be considered anytime a resident experiences a significant change in condition that warrants an ongoing assessment, and at least annually during routine assessments and negotiated service agreement reviews and updates.  This will ensure a systematic review of the plan and allow for adjustments as necessary. The regulation does mention that the facility can require, through policy and procedure, the resident’s family member to notify the facility immediately should changes in medications or treatment plans occur.

Whenever a family manages any aspect of a resident’s medications, those medications must remain on the assisted living premises whenever the resident is on the premises. This means, in the event something could occur that impeded the family from providing the medication service, staff could step in and manage the medications without a break in service.

Because of the wide range of expectations with this regulation, it is simple to miss a part or two. Some issues that rise to the level of citation include:
  • No family plan in place when one is warranted
  • The plan does not outline the name of the family member responsible for implementing the plan
  • The primary plan is vague and lacks detail that would allow staff to step in and fulfill the role if necessary
  • The alternate plan is missing
  • All signatures are not included
  • The resident’s significant medications are not stored onsite
  • The plan is not up-to-date and reflective of the services family is providing

It is essential to include the family plan as part of the full assessment and negotiated service agreement planning, to ensure it is up-to-date and reflects the services the family is providing. Furthermore, the facility should have systems in place to learn when a resident’s medications or treatments change to ensure proper monitoring for the resident’s overall functioning and condition, and to watch for any adverse medication side effects and take proper action. Enhanced communication methods amongst staff, residents, and their families will aid in making family assistance or administration of medications or treatments a successful endeavor.

If you have questions related to assisted living regulations, processes, training, or nursing, contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
SKILLED NURSING: RESIDENT RIGHTS - VISITATION
Over the last two years, no topic has been more controversial and frequently altered than the guidance surrounding resident visitation. With the retirement of the LTC Safe Start Plans and the adoption of the LTC COVID Response Plans, visitation remains an area of confusion for some facilities. It is important at this time to revisit the actual requirements that are in place related to visitation.

Primarily, facility leaders and staff must have a clear understanding of the resident’s rights regarding visitation. Those rights are the basis of the facility’s policy and procedures that staff will follow and of which residents/families are informed. Keep in mind that the Centers for Medicare & Medicaid Services (CMS) Requirements of Participation make it clear that the resident is the “locus of control” and the facility’s responsibility to “protect and promote” the rights of residents is paramount.

According to CFR 483.10 Resident Rights, F562 and F563, the resident has the right to receive visitors of his/her own choosing at the time of their choosing and in a manner that does not impose on the rights of another resident. The requirements further clarify that the facility must provide IMMEDIATE access to a resident by immediate family, other relatives of the resident, and others that are visiting with the consent of the resident (subject to the resident’s right to withdraw/deny).

The federal requirements state the facility must have written policies and procedures regarding the visitation, including any clinically necessary or reasonable restrictions. Also, the facility must inform each resident (or representative) of the resident’s visitation rights and facility policy, including any restrictions. All staff must be trained and have a clear understanding of their role in promoting and protecting resident rights.

Washington State regulation regarding these circumstances is, of course, Resident Rights, RCW 70.129. It is becoming increasingly a focus and priority for facilities to ensure that residents maintain their independence, rights, and choices. This includes who they visit with in their home and when. According to the resident rights’ statute, the resident has the right and the facility MUST NOT interfere with access to any resident by the following:
  • Any representative of the state.
  • The resident's individual physician.
  • The state long term care ombuds.
  • The agency responsible for the protection and advocacy system for individuals with developmental disabilities.
  • The agency responsible for the protection and advocacy system for individuals with mental illness.

The regulation further includes, subject to reasonable restrictions to protect the rights of others and to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident and others who are visiting with the consent of the resident.

The key phrases in the above section are “reasonable” and “protect the rights of others.” Under these circumstances, a facility can place reasonable restrictions. Each case should be evaluated with these words in mind and should be consistent with the facility’s policy and procedures.

RCW 70.129 also states the resident has the right to personal privacy including accommodations and meetings of family and resident groups. This does not require the facility to provide a private room for each resident; however, a resident cannot be prohibited by the facility from meeting with guests in his or her bedroom if no roommates object.

The facility MUST provide reasonable access to a resident by his or her representative or an entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.

Facilities are encouraged to evaluate each situation individually, keeping in mind that resident advocacy and protection is the primary focus. It is often beneficial, when faced with a difficult visitation situation, to first discuss it with the resident openly and honestly to the extent they can participate. Seek what the resident’s needs, wants, and concerns may be regarding this relationship/visitation. Attempt to come to a negotiated agreement that supports both the resident’s need for contact/visitation and the facility’s concerns.

The facility may need to facilitate a care conference or family meeting. There may be a need to contact the local ombuds or advocate for assistance. If the resident desires visitation from an individual known to be abusive, the facility will want to involve Adult Protective Services. No two scenarios are exactly alike, nor are the solutions.

While the above paragraphs review the requirements for visitation, facilities now have the extra challenge brought on by the COVID pandemic. CMS has issued QSO-20-39-NH REVISED (cms.gov), which clearly states “visitation is allowed for all residents at all times.” As of March 10, 2022, CMS has updated the FAQ document related to visitation, vaccination status, and COVID. As noted in the LTC COVID Response Plans facilities need to continue with visitor screening, social distancing, and source control. Facilities must also have adopted and implemented plans related to compassionate care and essential support persons. 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