When Residential Care Services (RCS) licensors enter the assisted living, staff tends to get a bit nervous. This is natural; after all, these state employees are going to observe your staff, interview residents, staff, and families, and review documents, all the while evaluating the facility’s processes and outcomes.

Starting any inspection off on the right foot makes a huge difference in the process itself. By organizing a survey manual/book and keeping it up to date, the inspection will certainly be a smoother process.

The contents of a survey book are up to the facility or company management. Looking at the DSHS inspection process helps to identify what the licensors will need by way of documentation, and what will get them started in their effort to complete the inspection in a timely manner.

Upon entry to the facility, a licensor will provide a staff member with ALF Request for Documentation form. This form includes a list of documents needed to conduct the full inspection. It’s a great idea, then, to include all documents listed on this form in the facility’s survey book.

  • This form outlines all assisted living residents who are currently in the facility, and their unique needs and services. There are directions on the last page of this document, highlighting the proper way to complete each column. Many providers have created a computerized version of this document, or had it imbedded into a secure online electronic health record platform. It is imperative this document remain up-to-date at all times. Assigning a staff member (or two) to add new residents, remove discharged residents, and update needs on a routine basis is key to ensuring this form remains a living, breathing document and ready for DSHS licensors at any time.
  • If the facility serves assisted living residents and nonresident individuals (“independent residents” or tenants), only include nonresident individuals in this document if this person is sharing an apartment with an assisted living resident. Indicate this somewhere on the form to alert RCS staff that a nonresident individual is included on the list.

This includes every staff person working both part time and full time, along with the position title, shift, hire date, and day and month of birth. The provider may use a similar form/format, so long as it has all data listed in the ALF Staff Sample/Record Review Form. An Excel spreadsheet might be easier to manipulate. Similar to the ALF Resident Characteristic Roster and Sample Selection Form, this document needs to be updated regularly. 
  • Name and phone number of administrator or designee, and/or nurse
  • The current and most recent three weeks of staff schedules (wellness/nursing, dietary/dining, and housekeeping)
  • Disclosure of Services, completed with the current administrator's name.
  • Proof of current liability insurance. The document must include the name and address of the facility.
  • The current and most recent four weeks of menus, including changes.
  • Pet records for all animals in the facility. This includes a recent veterinarian visit demonstrating the pet does not have any diseases communicable to humans, and proof of current vaccinations.
  • Proof of approved Construction Review projects, if any. This includes any physical plant changes completed since last full inspection.
  • Copies of letters demonstrating approval for waivers or exemptions to the licensing rules. Waivers are typically approved, in writing, by DSHS. A common example of an exemption might allow for two residents to share a sleeping room that is smaller than regulations allow.

Keeping all contents of the survey book up-to-date is critical to ensuring the inspection starts smoothly. A system to ensure this happens includes organization, dedicated trained staff members to perform the updates on a regular basis, and routine check-ins to ensure the binder is ready for an RCS licensor’s viewing. If you have questions about preparing for or responding to RCS inspections, please email Vicki McNealley or call her at (800) 562-6170, extension 107.
The Independent Informal Dispute Resolution (IIDR) process applies to Medicare-funded skilled nursing facilities or a dually- (Medicare and Medicaid) participating skilled nursing facility/nursing facility (SNF/NF). In accordance with sections 1819(h)(2)(B)(ii) and 1919(h)(2)(B)(ii) of the Social Security Act, and regulations at 42 CFR §488.331 and §488.431, state agencies will provide the facility with an opportunity to participate in an IIDR when the Centers for Medicare and Medicaid Services (CMS) imposes a civil money penalty (CMP) against a Medicare-participating SNF or a dually- (Medicare and Medicaid) participating SNF/NF and the penalty will be collected and placed in an escrow account pending a final administrative decision.
The IIDR process only applies to Medicare-funded nursing facilities and skilled nursing facilities which have had a Federal Civil Monetary Penalty imposed. CMS must approve all states’ IIDR processes, including the entity conducting the IIDR. CMS will look to the states to assure the validity of the IIDR decision-making processes and holds state agencies accountable for them.
According to the ALTSA/RCS Policy and Procedure for the IIDR process, following the imposition of a CMS CMP notice, RCS will screen out any IIDR requests that were not received timely by the date CMS indicated on the imposition of CMP notice or when the survey findings already have been the subject of an IDR for the deficiency citations at issue. An IIDR will still be held if the IDR was completed prior to the imposition of the CMP.

Within 30 calendar days of receipt of the IIDR request, RCS will send to the facility information in writing on the IIDR process, including that it will be conducted in writing only and the name and/or position/title of the person(s) who will be conducting the IIDR, including contact information. RCS will also notify the state ombuds and involved residents by letters of the request for an IIDR, providing contact information, how they can submit comments, and letting them know that the comments must be submitted within ten calendar days. If residents are incapacitated, RCS must notify the residents’ representative(s).
RCS then collects the written information from all parties and provides it to the IIDR entity. Following the IIDR entity’s review, there are three possible outcomes from the IIDR recommendation. They are as follows:

1.      No Changes Needed – This includes where the State Agency agrees with both IIDR recommendations for no change or change. The provider is given written notice of the final decision to the facility within the calendar days of receiving the written record from the IIDR entity, including the result for each deficiency challenged and a summary of the rationale for that result.
2.      RCS does not agree with IIDR entity recommendation – RCS will share any disagreement with the IIDR entity’s decision and the rationale for the disagreement with the IIDR entity. RCS will send the complete written record to the CMS Region X office for review and final decision.
3.      Changes Needed – RCS will change the deficiency(ies) citation content findings, as recommended, adjust the scope and severity, if necessary, have the IIDR Program Manager sign and date the revised CMS Form 2567, and recommend to CMS that any enforcement action imposed solely because of deleted or altered deficiency citations be reviewed, changed, or rescinded.
IDR and IIDRs can be confusing processes and timelines involved can easily be missed. If you have questions, please call Elena Madrid at (800) 562-6170, extension 105, or email.
The Centers for Medicare and Medicaid Services (CMS) has recently rescinded its July 2017 guidance that civil monetary penalties (CMPs) should be imposed for prior non-compliance on a per-instance basis only. CMS posted the rescission on their website, stating,  “Upon further consideration, CMS has determined that the agency should retain the discretion at this time to impose a per-day penalty where appropriate to address specific circumstances of prior noncompliance. We will work within CMS operations to apply such discretion, and any final notice of noncompliance will set forth the penalty, and the reason(s) for imposing per-instance or per-day penalties.” 

At this time, no new guidance has been posted. CMS staff have told us that while they understand we have questions, there is no additional information they can provide at this time. We are urging CMS to reconsider and exploring other options to address this issue. 

As additional background, the 2017 guidance is the subject of litigation filed by Consumer Voice and AARP. The Department of Health and Human Services (HHS) on Monday filed a motion for an extension of time in this case and noted that the litigation is moot now that the guidance has been rescinded. If you have questions, please email Elena Madrid or call her at (800) 562-6170.
303 Cleveland Avenue SE, Suite 206 | Tumwater, Washington 98501
Tel (800) 562-6170