A plan of correction (POC) is required for every WAC violation noted in a Statement of Deficiencies (SOD) report. WAC 388-78A-3152 states that, by signing the attestation of correction statement beneath each citation in the SOD, the assisted living representative is indicating that the deficiency is or will be corrected and the date by which the correction will be completed. The SOD, with the signed and dated attestations, must be returned to the Department within 10 calendar days of receiving the report.

While the POC for each deficiency is not sent to DSHS, it must be filed with a copy of the signed SOD on the assisted living facility premises and shared with licensors or complaint investigators upon request. Residents also have the right to review the facility’s POC.

In writing a POC, it is important to grasp the intent of the citation, so the correction is targeted and effective. Read and re-read the citation to determine what the specific failed practice is prior to developing the POC. Then, working with other pertinent staff members in the facility, devise a workable POC that includes the following six parts:
  1. HOW THE HOME WILL CORRECT THE ISSUE FOR EACH RESIDENT LISTED IN THE CITATION. This demonstrates that the facility took action to address specific resident issues identified by DSHS staff. List each resident by number in this part of the POC, and state how the facility corrected the issue for that resident. If no resident was listed in the citation, state this. If a resident was listed in the SOD but no longer lives in the assisted living, state this.
  2. HOW THE HOME WILL PROTECT OTHER RESIDENTS IN SIMILAR SITUATIONS. This part prompts you to look beyond the residents listed in the citation, to others who might fall into the same category. Completing this part of the POC allows you to see if systems are broken and lays the groundwork to fix that system and effectively minimize the likelihood of a re-citation on the same issue.
  3. MEASURES THE HOME WILL TAKE OR SYSTEMS IT WILL CHANGE TO ENSURE THE PROBLEM DOES NOT RECUR. This is a proactive measure that encourages an honest look at how systems are operationalized in the building and by the company. Leadership must be willing and able to change and adapt new programmatic measures to fix the core issue(s) that led to the citation.
  4. HOW THE HOME PLANS TO MONITOR ITS ONGOING PERFORMANCE TO SUSTAIN COMPLIANCE. Beyond planning, this component of the POC prompts a futuristic focus on maintaining the new system or method. This might include data collection and analysis and/or scheduled look-in steps to determine staff’s compliance with the updated system.
  5. DATE THE CORRECTIVE ACTION WILL BE COMPLETED. The citation must be corrected within 45 days from the last date of inspection, or sooner depending on the severity of the situation. If an administrator needs additional time, the DSHS field manager must be consulted, and the extension approved.
  6. NAME AND TITLE OF THE PERSON RESPONSIBLE FOR THE CORRECTION. This person should have the ability to make changes and be responsible to oversee the system’s operation.

The POC may require updating, based on the outcome measures put in place to correct the issue. If updates or complete re-writes are necessary, document as such and file with the original POC.

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.
Smoking is still a topic that is fraught with personal opinions, safety hazards, resident rights, and multiple regulations. Every facility needs to remain hypervigilant related to smoking, whether or not the facility “permits” resident smoking. Included in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual (SOM) Appendix Q-Guidelines for Determining Immediate Jeopardy are triggers that include unsupervised resident smoking with known safety risks (failure to prevent neglect) and smoking in high risk areas (failure to provide safety from fire, smoke and environment hazards).

According to the Code of Federal Regulation (CFR) 483.90 Physical Environment (F926), the facility must establish policies, in accordance with applicable federal, state, and local laws and regulations, regarding smoking, including tobacco cessation, smoking areas and safety, for both smoking and non-smoking residents. CMS directs surveyors to look for signs of smoking by residents, staff, visitors, guests, and non-staff, as well as to look for smoking areas both inside and outside the facility. It is imperative that facilities take a proactive and routine maintenance approach in monitoring these same issues even if they are a “non-smoking” facility. Do visitors, staff, and/or residents discard their cigarette butts in flower gardens, decorative bark, or trash receptacles before entering the facility? Are there places around the corner or behind dumpsters where people are known to congregate for a quick smoke? These areas need to be monitored and addressed accordingly.

If your facility allows smoking or if there is evidence of smoking, you can expect the surveyors to interview and observe residents regarding smoking in the facility. They will ask if the facility allows smoking and how smoking is managed, as well as review the policies and procedures. In facilities that allow smoking of tobacco and/or cannabis products, assessment of each resident’s capabilities and deficits determines whether or not supervision is required. If the facility finds that the resident needs assistance and supervision for smoking, the facility must include this information in the resident’s plan of care. The resident must also be reassessed when circumstances or changes occur that affect or may alter their cognitive and physical capabilities (see CFR 483.25(d) Accidents/F689 for additional information). This can include such things as a change in medication regime, cognitive and/or physical decline, delirium, mental health changes, etc. The plan of care must be changed accordingly, and the necessary supervision/assistance implemented to address the situation and protect all residents’ safety. This may mean providing whatever supervision and/or support is necessary until alternatives are explored. For example, a resident may return from a medical procedure and still be under the influence of sedation. As soon as they get back to the facility, the resident may want to go outside to smoke. Are they safe to do so? Do staff on weekends and off-hours know how to manage this situation? It is not enough to repeatedly “remind” the resident not to smoke when it is known they are non-compliant or do not have the cognitive abilities to remember.

Facility policies must describe the methods by which residents are considered safe to smoke without supervision. These methods may include, but are not limited to, assessment of a resident’s cognitive ability, judgement, manual dexterity, and mobility. According to CMS, facilities should err on the side of caution and provide staff, family, or volunteer supervision when unsure whether or not a resident is safe to smoke unsupervised. Facilities are directed to also ensure resident safety by such efforts as informing visitors of smoking policies and hazards to prevent smoking-related incidents and/or injuries.

While most facilities over the years have chosen to go “non-smoking,” it is important to remember a change in the facility’s policy to prohibit smoking does not affect current residents who smoke. According to CMS and state agency guidance, current residents are to be allowed to continue smoking in an outside, designated area. Part of the facility’s obligation to ensure the safety of designated areas includes protection of residents from weather conditions, non-smoking residents from secondhand smoke, portable fire extinguishers, and ashtrays made of noncombustible material and safe design. Metal containers with self-closing covers into which ashtrays can be emptied must be readily available.

Further guidance regarding resident smoking regulations can be found in NFPA 101, the Life Safety Code at 19.7.4, which addresses smoking, requirements for signage, prohibiting smoking by residents classified as not safe/responsible, and disposal of smoking materials. Also, see CMS S&C Memo 12-04-NH, Alert: Smoking Safety in Long Term Care Facilities and the DSHS/ALTSA Dear Administrator Letter NH #2015-030, Use of Electronic-Cigarettes in Long Term Care Facilities for additional information. Also, the Dear Administrator letter NH# 2015-014 addresses the use of cannabis.

If you have questions, 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