One of the first steps in any full inspection involves a facility tour. As the leader in assisted living, it is essential the administrator manage the tour to set the tone and offer a direct point-of-contact for answers to licensors’ questions. This article outlines what specific areas the licensors will observe, and what they are looking for. Perhaps more importantly, this outline can guide how to conduct a facility tour and, ideally, do so independently to identify potential areas of concern before a DSHS licensing visit. It is helpful to refer to the full licensing inspection process to determine DSHS roles and expectations during the tour.

When DSHS licensors arrive onsite, the tour immediately follows their initial “settling in” to their designated workspace. It is important that someone in the facility is prepared to lead the licensors on a tour. Ideally, that person includes the administrator, so the tone of the tour is effectively guided. The maintenance supervisor is typically also included in the tour, as this person generally has all facility keys and can access all storage areas with ease. Should the administrator be unavailable for any reason, the tour cannot be delayed. It is crucial, then, that the facility train multiple staff in the intricacies of effectively managing this tour.

The tone of the entire licensing visit begins with the tour. The administrator’s friendly demeanor with licensors comes across to residents, visitors, and staff as the development of a collaborative relationship.

The licensors will make observations of residents and staff, as well as structures and furnishings located inside and outside the building. They will conduct informal interviews during the tour.

By following the DSHS Attachment I, Environmental Observations form, the facility can prepare for a tour and anticipate the licensors’ focal areas during the walk-through. The following areas are covered:

Quality of life, resident rights
  • Do residents look healthy/happy/engaged? Are staff knocking on doors before entering (privacy)? Are staff/resident interactions respectful? Are residents treated with dignity? Is the facility homelike, with comfortable furnishings, adequate lighting, and opportunities to gather and enjoy activities?

Physical environment – inside and outside
  • Postings, including current assisted living license, CRU/hotline poster, ombuds contact information, most recent DSHS inspection report with plan of correction, any COVID-related postings (visitation, necessary signage for hand hygiene/PPE, etc.).
  • Is the area safe? Any hazards noted? Does equipment work properly? Are there any objectionable odors?

Maintenance and housekeeping
  • Are chemicals/supplies stored securely? Does laundry staff follow a clear dirty-to-clean path? Are ceiling vents operational? Do fire doors close automatically? Is water temperature between 105 and 120 degrees?

All storage rooms with items needed to be kept from residents’ access need to be locked at all times. This includes but is not limited to the wellness center, medication/ nursing supply storage areas, commercial laundry rooms, housekeeping closets, and administrative offices. While licensors will need to look in all of these locations during the tour, the facility representative will need to gain access to these locations/rooms with keys or other accessible means.

Observations will take place specific to infection control standards throughout the tour and the remainder of the inspection. Hand hygiene, cleaning/disinfection practices, and proper donning and doffing of PPE will be observed, with follow-up interviews for clarification as necessary. All COVID-19 related mandates, including check-in methods, masking of all staff, visitors, and residents will also be observed.

Licensors will ask questions during the tour, to learn about individual facility processes and to clarify issues observed. Be sure to answer these questions promptly and thoroughly, without offering additional information unless requested.

Finally, if any facility employee determines failed practice during the tour, fix issues immediately and preferably before the licensors complete the inspection. RCW 18.20.400 allows for limited instances where correction of a violation prior to the exit conference might result in the licensors not including the issue as a citation on the Statement of Deficiencies.

Prepare for the tour by practicing. Include the maintenance supervisor and other essential staff in developing a system to conduct the facility tour and follow up on any issues discovered during this routine walk-through of the building. If you have questions about the tour or any other aspects of the licensing process, contact Vicki McNealley at 1-800-562-6170 extension 107 or via email.
When a facility receives an enforcement action from the Department of Social and Health Services (DSHS) and/or the Centers for Medicare & Medicaid Services (CMS) because of a citation, it is often confusing. 

It is important to note that the Department—in this case DSHS—has the authority given by the Washington State Legislature to license, inspect, and investigate what is defined by RCW 18.20 as a “nursing home.” DSHS has also been given the authority to impose enforcement remedies because of provider non-compliance with the regulations and requirements for nursing homes in our state. The Department has several enforcement actions (remedies) at their disposal; some are optional, and depending on the circumstances, some are mandatory or automatic.

The list of State remedies includes the following:
  • Stop placement.
  • Immediate closure of a nursing home, emergency transfer of residents, or both.
  • Civil fines.
  • Appoint temporary management.
  • Petition the court for the appointment of a receiver in accordance with RCW 18.51.410;
  • License denial, revocation, suspension or nonrenewal.
  • Denial of payment for new Medicaid admissions.
  • Termination of the Medicaid provider agreement (contract).
  • Department on-site monitoring as defined under WAC 388-97-0001; and
  • Reasonable conditions on a license as authorized by chapter 74.39A RCW. Examples of conditions on a license include but are not limited to training related to the deficiency(ies), consultation to write an acceptable plan of correction, and demonstration of ability to meet financial obligations necessary to continue operation.

Washington Administrative Code (WAC) 388-97-4460 states that in accordance with RCW 18.51.060, the Department must impose a stop placement order when the Department determines that the nursing home is not in substantial compliance with applicable laws or regulations and the cited deficiency(ies):
  • Jeopardize the health and safety of the residents; or
  • Seriously limit the nursing home's capacity to provide adequate care.
  • When required by RCW 18.51.060 (3), the Health Care Authority must deny payment to a nursing home that is certified to provide Medicaid services for any Medicaid-eligible individual admitted to the nursing home.

The Department must deny, suspend, revoke, or refuse to renew a proposed or current licensee's nursing home license in accordance with WAC 388-97-4220.
There are also optional remedy circumstances. According to WAC 388-97-4480, the Department must consider the imposition of one or more optional remedy(ies) when the nursing home has:
  • A history of being unable to sustain compliance.
  • One or more deficiencies on one inspection at severity level two or higher as described in WAC 388-97-4500;
  • Been unable to provide an acceptable plan of correction after receiving assistance from the Department about necessary revisions.
  • One or more deficiencies cited under general administration and/or nursing services.
  • One or more deficiencies related to retaliation against a resident or an employee for whistle blower activity under RCW 18.51.220, 74.34.180 or 74.39A.060 and WAC 388-97-1820;
  • One or more deficiencies related to discrimination against a Medicare/Medicaid client under RCW 74.42.055, and Titles XVIII and XIX of the Social Security Act and Medicare/Medicaid regulations; or
  • Willfully interfered with the performance of official duties by a long-term care ombudsman.

When the Department imposes an optional remedy(ies), the Department will select more severe penalties for nursing homes that have deficiency(ies) that are:
  • Uncorrected upon revisit.
  • Recurring (repeated).
  • Pervasive; or
  • Present a threat to the health, safety, or welfare of the residents.

The Department will also consider the severity and scope of cited deficiencies in accordance with WAC 388-97-4500 when selecting optional remedy(ies). The WAC goes on to state that such consideration will not limit the Department's discretion to impose a remedy for a deficiency at a low-level severity and scope and that each deficiency cited by the Department for noncompliance with a statute or regulation is a separate deficiency subject to the assessment of a separate remedy. Each day upon which the same deficiency occurs is a separate deficiency subject to the assessment of a separate remedy. It is important to note that these remedies are separate and not dependent on any of the CMS/federal enforcement remedies or actions.

Additional information and resources can be found on the ALTSA website, including the DSHS Operating Procedures, DSHS Request of Administrative Hearing Form, and a DSHS/RCS Webinar Recording regarding SNF Enforcement Remedies. If you have questions, call Elena Madrid at (800) 562-6170, extension 105, or email.
303 Cleveland Avenue SE, Suite 206 | Tumwater, Washington 98501
Tel (800) 562-6170