Many administrators and other assisted living leaders have entered the workforce during COVID-19.  Because the licensing inspections were on hold for over a year, it is likely you have not experienced a full survey (often called inspections in assisted living). This first installment of Survey and Regulatory Update will focus on the very basics: who is coming, and why.

The law requires DSHS conduct a full inspection at least every 12 – 18 months, with a general average of 15 months. Reality is, however, DSHS can initiate a full inspection at any date.

Most assisted living full inspections are conducted during normal business hours, and generally last anywhere from three to five days. The state has discretion, however, to come onsite for an inspection at any time of day and night, and on any day of the week, and occasionally do so.

The licensing inspection begins well before the licensors step foot on the assisted living property. The team first determines the last date of full inspection and schedules the next inspection so that it is unpredictable; this may mean they arrive earlier than anticipated by you, or much later. The window of opportunity is wide, and therefore, it is imperative that you and your team are always prepared.

The team reviews your building’s file at the DSHS office; considerations are taken regarding sample residents interviewed previously, as well as citation trends and repeated issues that have come up in previous inspections. A review of complaint investigations since your last full inspection will also take place.

The team will inquire with the ombuds as well as the DSHS case manager, if you have a Medicaid contract, regarding any concerns or issues these individuals may have.

The licensing team is made up of registered nurses and other allied health personnel such as dieticians, social workers, occupational therapists, and others. Any clinical observations must be conducted by a registered nurse. While your point-of-contact is the team leader while the inspection team is onsite, later concerns or questions regarding the inspection process and regulatory issues should be shared to the inspection team’s supervisor, the field manager.

If you are new to the assisted living profession, please familiarize yourself with the DSHS website as well as the SOP manual that the DSHS licensors follow for every full inspection.

The next article will focus on steps to take to effectively initiate a full inspection, once licensors arrive at your front door. If you have questions on the inspection process, please email Vicki McNealley or call her at (800) 562-6170, extension 107.
With the reimplementation of full recertification and re-licensure surveys by Residential Care Services (RCS), it is important for SNF staff to be familiar with the federal and state survey processes and what to expect when the RCS inspection team arrives at the facility. Many LTC facilities have new staff or staff that have not been through a RCS inspection. Now is the time to train staff regarding the process and your facility expectations when survey arrives.

It is important to note that CMS updated LTC Survey Process Procedure Guide on February 6, 2021. A summary of some of the recent changes/direction to surveyors related to COVID-19 are highlighted below:
  • The maximum number of complaints and/or Facility Reported Incidents (FRIs) that should be brought onsite for investigation during the full survey was increased due to state complaint backlogs. This number will be used to identify the maximum number of complaints/FRIs that may be included in the initial pool since the number is indicative of the facility census size. This information can be found in Appendix A of the LTC Survey Process Procedure Guide.
  • Surveyors are directed by CMS to review CDC, state/local public health information, if available, to be aware of the COVID-19 status of the facility including the COVID-19 county positivity rate.
  • Where practical, one surveyor should be assigned to COVID-19 positive residents only. Additionally, a different surveyor should be assigned to the COVID-19 suspected residents, or those residents under observation. Once the surveyor that is assigned to the COVID-19 unit enters the unit, the surveyor should stay on that unit for the remainder of the day while completing the investigation and tasks specific to that unit.
  • Surveyors are directed to ask the facility about their policy for entering/exiting COVID-19 units.
  • Surveyors are told by CMS that the facility should complete the facility matrix within four hours (check the conference room periodically). Once the matrix is received, each surveyor will review the matrix for residents in their assigned area to identify any substantial concern that should be followed up. At least one resident who smokes, one resident who is receiving dialysis, one resident on hospice, one resident on a ventilator, and two residents who are on Transmission-Based Precautions (suspected or confirmed COVID-19 and/or non-COVID-19 TBP) should be included in the initial pool for the team if available. If one resident is on TBP for COVID-19 and TBP for a non-COVID-19 reason, it is acceptable to include just the one resident.
  • Surveyors should conduct rounds until they can determine whether all observation areas should be answered with No Issues/NA, Further Investigation, or NA for hospice, ventilator, transmission-based precautions, and smoking.
  • If dining rooms are not being used during the PHE, surveyors should determine whether residents are receiving assistance and ensure observation of room tray delivery.
  • If a surveyor is restricted to a specific area of the building (e.g., COVID unit or cohorting), the surveyor should not be physically present with any team member. The surveyor should meet virtually or by telephone (on his/her own) with the team throughout the survey. In that case, the team will have to retrieve that surveyor’s data securely (e.g., through email).
  • Surveyors should sample at least three staff, including at least one staff member who was confirmed COVID-19 positive or had signs or symptoms consistent with COVID-19 (if this has occurred in the facility), for purposes of determining compliance with infection prevention and control national standards such as exclusion from work, as well as screening, testing, and reporting.
  • Sample three residents for purposes of determining compliance with infection prevention and control national standards such as transmission-based precautions (TBP), as well as resident care, screening, testing, and reporting.
  • Include at least one resident who was confirmed COVID-19 positive or had signs or symptoms consistent with COVID-19 (if any).
  • Include at least one resident on transmission-based precautions (if any) for a non-COVID-19 reason.
  • If one resident is on TBP for COVID-19 and TBP for a non-COVID-19 reason, it is acceptable to include just the one resident.
  • Sample five residents for influenza and pneumococcal immunizations.
  • Surveyors are directed that during the PHE, for residents who participate in the Resident Council interview and are not on transmission-based precautions (TBP), it is important for everyone including the assigned surveyor to wear a face covering/mask as appropriate, maintain social distancing and perform hand hygiene at all times.

It is important to be prepared 24/7 for your nursing facility survey. With the reimplementation of surveys, WHCA is interested to hear from facilities the outcome and any feedback regarding the survey process. Please email Elena Madrid or call her at (800) 562-6170, extension 105, with survey feedback or questions.
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