It seems inevitable that at some point the facility where you work will receive a Statement of Deficiencies (SOD) report. The handling of this document may seem simple on the surface – read it, sign it, fix the issues addressed, and file it away.
The fact is the reading of this document is not simple at all. There is a lot that goes into reading a SOD to fully grasp if the citation is valid, warranted, complete, and accurate.

Following an inspection, the department must make written notice to the assisted living facility of any violation of law or rule. WAC 388-78A-3150 states the department will give the administrator or the administrator’s designees a written statement of deficiencies report specifying any violations of chapters 18.20 RCW, 70.129 RCW, or 74.34 RCW, this chapter, or any other applicable laws or rules that the department found during the inspection or complaint investigation.

When receiving a SOD, take time to read it thoroughly, and most likely more than once. The document itself comes with a cover letter in addition to the citations. 

COVER LETTER. This letter to the administrator outlines the purpose of the unannounced visit (full inspection, follow-up inspection, and/or complaint investigation). Contents of the cover letter include:
  • Notice of sanctions if any are imposed. This might include civil fines, stop placement of admissions, and/or a condition on the license. Details of the sanction(s), including which regulations pertain to the sanction(s), will be included.
  • Directions on how to attest to a plan of correction, and submit that to the department.
  • Appeal rights, including how to request an informal dispute resolution (IDR) and, if you received a sanction, how to request a formal administrative hearing should you disagree with any or all of the citations.
  • IDR requests must be made in writing by the tenth working day from receipt of the SOD.
  • Hearing requests must be made in writing within 28 days of receipt of the SOD.
  • Information regarding who to contact should you have questions. This person is your DSHS field manager.
  • List of individuals and agencies receiving a copy of the letter and your SOD. This includes the Residential Care Services (RCS) field manager and regional administrator, the Home and Community Services (HCS) and Developmental Disabilities Administration (DDA) regional administrators, the Washington State Long Term Care Ombuds, Office of Financial Recovery (if civil fines are involved), DSHS headquarters central files, and Disability Rights Washington (DRW).

FIRST PAGE OF THE SOD. This includes information on the type of inspection that was done, and the dates of inspection. The number of sampled residents selected for review is included, as well as the name of the licensor(s) and/or complaint investigator(s) that conducted the inspection. The field manager’s signature and the date s/he signed the document is on this page, as is space for the facility administrator or representative to sign and date, demonstrating understanding of the need to always follow all regulations.

From this point on, the SOD goes in this order:
  • RCW OR WAC CITED. This will include the number and subsections, along with the verbiage from the regulation/law. This information identifies what the failed practice is, specifically.
  • The following statement: “THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:”
  • AN INTRODUCTORY “BASED ON” STATEMENT. This statement highlights how the specific citation was determined. It includes one, two, or all three of the following methods:
  • Observation. The licensor/complaint investigator witnessed an event or other observable data that supported the citation. This is the strongest single method to determine failed practice.
  • Interview. The licensor/complaint investigator spoke with someone – a resident, staff member, collateral contact, or other pertinent person – that determined or supported evidence of failed practice. Since interviews could potentially fall to a “he-said-she-said” issue, data collected during an interview generally accompanies either observation and/or record review to support the citation.
  • Record review. The licensor/complaint investigator reviewed documentation or other record that determined or supported failed practice. Record review generally accompanies either observation and/or interview to support the citation.
  • These data collection methods are added to the statement to outline what the facility failed to do and how this failure impacted residents. This part of the citation may raise some readers’ eyebrows; after all, even with minor citations this wording about failure can make even the best facility appear sub-par.
  • “FINDINGS INCLUDE” statement goes into detail with specific residents (numbered) and staff (lettered) to support the failed practice. When reading this part of the SOD, know that citations are strongest when all three – observation, interview, and record review – are included. Subsequent details of the SOD should support these claims. So, for example, if the introductory “based on” statement indicates that observations and record reviews were conducted, details of these two data collection points should be included in the findings section of the citation.
  • PLAN/ATTESTATION STATEMENT. This box at the end of the citation prompts the administrator or designee to identify the date by which the facility will achieve compliance with the cited regulation, and assurances that a system will be in place and monitored for continued compliance. A signature and date line are provided and must be filled in. A provider has a maximum timeframe of 45 days to fix a citation unless an urgent issue warrants less time.

When reading through the SOD, ensure you have ample time and are in a good frame of mind. Read through it first to discover what areas were cited, and the details of that citation. Read through it again (possibly more than once) to determine if (a) the findings in the SOD match the citation (or whether this issue possibly should have been cited in another section of the WAC), (b) the information is accurate and reflective of actual events, and (c) vital information is missing that would have otherwise changed the citation.

Discuss upcoming plans with your leadership team, including any inclination to request an IDR or, if a sanction was imposed, also an administrative hearing. Regardless of interest in arguing the citation, the administrator or designee must develop a plan of correction.

The next article will focus on methods to write a plan of correction. If you have questions on the assisted living inspection process or reading a SOD contact Vicki McNealley via email, or call her at (800) 562-6170 extension 107.
On November 12, 2021, CMS released QSO Memo 22-02-All related to Changes to COVID-19 Survey Activities and Increased Oversight in Nursing Homes. In the memo, CMS states the following:

“Inappropriate use of antipsychotic medications continues to be an area of concern related to quality of care. Nursing homes are required to ensure that each resident’s drug regimen is free from unnecessary drugs (§ 483.45(d)). SAs (state agencies) should continue to focus their efforts on identifying the inappropriate use of antipsychotic medications and emphasize non-pharmacologic approaches and person-centered care practices.”

With CMS’s charge to state agencies to focus on psychoactive medications, facilities in Washington can expect this to be focused on during RCS full surveys and associated complaint investigations. For facilities to effectively comply with the requirements outlined in CFR 483.45 Pharmacy Services, it is important to understand there are two separate requirements for as-needed (PRN) orders for psychotropic medications and antipsychotic medications. A psychotropic drug is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic medications include, but are not limited to, medications in the following categories:
  • Antipsychotic
  • Antidepressant
  • Antianxiety
  • Hypnotic

The interpretive guidance found in F757 and F758 identify the following:
Evaluation of the resident before writing a new PRN order for antipsychotic medication must include the following:
  • The attending physician or prescribing practitioner must directly examine the resident and assess the resident’s current condition and progress to determine if the PRN antipsychotic medication is still needed.
  • The attending physician or prescribing practitioner should, at a minimum, determine and thoroughly document the following in the resident’s record:
  • Is the antipsychotic medication still needed on a PRN basis?
  • What is the benefit of the medication to the resident?
  • Have the resident’s expressions or indications of distress improved because of the PRN medication?
It is also vitally important for facilities to ensure compliance with the pharmacy review guidelines. The pharmacist must report any irregularities to the attending physician, the facility’s medical director, and director of nursing. These reports must be acted upon. Irregularities include but are not limited to any drug that meets the criteria set forth as an unnecessary drug. Any irregularities noted by the pharmacist during the pharmacy review must be documented on a separate, written report that is sent to the attending physician, the facility’s medical director, and director of nursing. The report must list at a minimum the resident’s name, relevant drug, and the irregularity identified.

The attending physician must document in the resident’s record that the identified irregularity has been reviewed and what, if any, action has been taken to address the irregularity. If there is no change in the medication, the attending physician should document his/her rationale in the medical record.

The facility must develop, implement, and maintain policies and procedures for a monthly drug regimen review that include timeframes for the different steps in the process and steps the pharmacist must take when s/he identifies an irregularity that requires urgent action to protect the resident.

If you have questions or would like additional information about the skilled nursing survey process, please email Elena Madrid or call her at (800) 562-6170, extension 105.
303 Cleveland Avenue SE, Suite 206 | Tumwater, Washington 98501
Tel (800) 562-6170