May 5, 2023
AL | Who Can Conduct Resident Assessments in Assisted Living?

This article was originally sent via an emailed Survey and Regulatory newsletter in March 2022. While still accurate, new updates have come from DSHS because of WHCA’s efforts to support a member who received a citation and subsequently prevailed during an informal dispute resolution. This Management Bulletin was shared with all Residential Care Services (RCS) staff on March 24, 2023 and includes a link to the Dear Provider Letter sent to assisted living providers on the same date.

Assisted living regulations are vague and thus cause confusion regarding the expectations surrounding who can conduct resident assessments. This article aims to provide clarification on this topic.

Perhaps one of the most confusing aspects in the entirety of WAC 388-78A lies with the use of the word “assessment.” This word provokes thoughts of a nurse conducting a head-to-toe patient assessment or a medical doctor assessing a patient’s current ailment. While nursing assessments are necessary in assisted living, for those residents needing some level of intermittent nursing services, the remainder of the assisted living resident assessment would be better termed “evaluation.” The vast majority of information gathered during an assessment is really evaluating the resident’s needs and preferences and requires very little by way of clinical expertise.

Depending on the type of assessment, the assisted living provider might utilize staff with differing levels of education and experience.

Preadmission Assessment

The preadmission assessment is conducted before the resident moves in. This assessment must be completed by a “qualified assessor” whose education and experience are outlined in WAC 388-78A-2080 and includes a person with any of the following:

  • A master’s degree in social services, human services, behavioral sciences or an allied field and two years social service experience working with adults who have functional or cognitive disabilities.

  • A bachelor’s degree in social services, human services, behavioral sciences or an allied field and three years social service experience working with adults who have functional or cognitive disabilities.

  • A valid Washington state license to practice nursing.
  • This could be an LPN, RN, or ARNP

  • A state license to practice medicine.

  • Three years of successful experience acquired prior to September 1, 2004, assessing prospective and current assisted living facility residents in a setting licensed by a state agency for the care of vulnerable adults, such as a nursing home, assisted living facility, or adult family home, or a setting having a contract with a recognized social service agency for the provision of care to vulnerable adults, such as supported living.

Regardless of who performs your facility’s preadmission assessments, ensure documentation supports the individual’s qualifications.

14-Day and Ongoing Assessments

All residents new to the facility must have a full assessment within 14 days of moving in and must address all aspects of WAC 388-78A-2090. Ongoing assessments are defined in WAC 388-78A-2100 and include:

  • Annual (or more often, based on the facility’s policies and procedures) full assessment as outlined in WAC 388-78A-2090

  • Focused area(s) of assessment based on:
  • A resident’s change in condition
  • Times when a resident’s negotiated service agreement no longer addresses the resident’s current needs and preferences
  • Times when a resident has an injury requiring the intervention of a practitioner
The person conducting the 14-day assessment as well as the ongoing assessments does not have to meet the stringent education and experience standards that are required for preadmission assessments. Regarding ongoing assessments, the regulation states:

“Ensure the staff person performing the on-going assessments is qualified to perform them.”

Facility management could legally and feasibly train a staff person to conduct ongoing assessments to “ensure the staff person…is qualified to perform them.” It is suggested that any training provided to this individual(s) is documented, and any facility policy and procedure on the topic addresses who in the facility is qualified to perform ongoing assessments. Ideally this task is included in the individual’s job description.

Nursing Assessments

Residents who need nursing services will need a nursing assessment. This assessment is focused on the resident’s condition(s) that warrant nursing care and can only be conducted by a registered nurse (RN). The Washington State nurse practice act outlines the differing roles and responsibilities of the RN and the LPN. An LPN can make observations, gather data, and provide relevant information as part of a nursing assessment, while the RN is responsible for conducting the nursing assessment.

WAC 388-78A-2310 captures what constitutes intermittent nursing services; any resident’s needs that fall into any or all these categories would require a RN assessment, specific to these issues and/or resident conditions. Topics that warrant a RN’s assessment include:

  • Medication administration. This service is a complex one, that involves times when a resident cannot perform the “final step” of medication self-administration or cannot accurately direct others to perform the task. Common medication administration provisions include times when a nurse must inject medications (vitamin B12 injections, for example) or spooning medications into a resident’s mouth when the resident is unaware s/he is receiving medications.

  • Administration of health treatments. This too is a vague term, and requires considerations of tasks that typically fall to licensed nurses such as prescribed wound care/wound dressing changes or indwelling urinary catheter changes.

  • Diabetic management, including whenever staff must perform blood glucose monitoring for a resident (piercing of the skin) and/or insulin injections. Individual facilities/companies may include other services under diabetic management in order to offer enhanced oversight of the condition, such as monitoring the extremities for wounds/skin breakdown, diabetic nail care, or even nursing oversight of any resident diagnosed with diabetes.

  • Nonroutine ostomy care. This includes changing the protective wafer around a stoma and observing/providing skin care to treat or minimize skin breakdown where the wafer is applied.

  • Tube feeding.

  • Nurse delegation.

It is reasonable that an assisted living facility has more than one staff person who can complete resident assessments. No matter the type of assessment conducted, the facility should have a system in place to ensure assessments are done timely and by the appropriate, trained person(s).

AL Questions?
Please email Vicki McNealley or call her at 1-800-562-6170 extension 107.
SNF | Additions & Changes to Quality of Care FTags Effective October, 2022

Moving into 2023, it is important to note the changes the Centers for Medicare & Medicaid Services (CMS) made to the State Operations Manual (SOM) guidance and F-tags related to the Quality of Care requirements. As you all know, these changes became effective in October of 2022 and review of current citation data reveals that Quality of Care citations remain in the top ten citations both in Washington and nationally. The following article provides an overview of some the CMS expectations outlined in Appendix PP.

CMS clarified in F686, Skin Integrity (Pressure Sores) that when determining whether damage to the skin and underlying tissue is a pressure injury/pressure ulcer it depends on the staging of the damaged tissue. They also added wording that the facility must provide treatment “and services” to heal a pressure injury, “to prevent infection” and development of additional pressure injuries. They also changed expectations regarding risk assessments. Risk assessments related to skin breakdown should occur upon admission, weekly for the first four weeks after admission, and then “quarterly” (rather than monthly), or whenever there is a change in condition.

CMS added new language in F687, Foot Care related to infection prevention practices for foot care equipment (nail clippers, scalers, files). Facilities are expected to ensure that the following measures are in place related to foot care:

  • Establish a process for reusable medical devices.
  • Clarified meaning of “staff” to include employees, MD, podiatrists, consultants. contractors, volunteers, caregivers who provide care/ services to residents on behalf of the facility, students.
  • Added a reference to the infection prevention and control F-tag for foot care related to maintaining a separation of clean/contaminated equipment.

In F689 Accidents, CMS added specific language and clarification regarding resident use of electronic cigarettes. The guidance identifies risks associated with the use of electronic cigarettes/vaping to include health effects to the user as well as second-hand exposure, potential nicotine overdose by ingestion or skin contact, and explosion or fire caused by the battery. CMS expects facilities to oversee the use of these devices and address the use of such in their smoking policies. Specifically, facility policies should cover the unique characteristics and risks of electronic cigarettes/vaping, how staff will supervise a resident that needs supervision, how it identified which residents use e‐cigs and how to manage the batteries and refill cartridges. Facilities must ensure resident safety while honoring a resident’s right to use the device and how they protect other residents that do not want to be exposed.

Also, under F689, CMS added information to clarify resident elopements. A resident that leaves the premises or a safe area without the knowledge or supervision of staff is considered an elopement. CMS clarified information related to residents leaving “against medical advice” (AMA). CMS states the facility is responsible for knowing if a resident leaves the building. A resident who leaves the facility without facility knowledge of the departure, despite efforts to explain the risks, would likely be an AMA discharge. Facility documentation should show attempts to provide the resident with other options and risks associated with leaving AMA and the time the facility became aware of the resident leaving.

Due to a resident with SUD potentially being at increased risk for leaving the facility to satisfy an addiction, additional guidance to address the safety of residents with substance use disorder (SUD) was also included under F689. The resident should be assessed for the risk of elopement and interventions should be care planned to address this risk.

Facilities should also assess the resident for the risk of drug use in the facility. Staff should have knowledge of the signs of drug use and be prepared to address emergencies related to substance use such as opioid reversal agents, CPR, and contacting emergency services. It is important to note that CMS acknowledges that if a resident overdoses, it does not necessarily mean that facility noncompliance exists. If evidence shows that a facility took steps to increase monitoring, and despite this effort, the resident overdosed between monitoring checks, then noncompliance may not be present.

Minor changes were made to Incontinence, F690 to clarify the regulatory language is specific to bowel incontinence, not bowel management.

Requirements outlined in Parenteral Fluids, F694 added guidance related to the frequency of assessments. An exact timeframe is not specified but the guidance provides factors which could affect how the frequency of assessments is determined, such as the resident’s ability to report symptoms (pain or redness), the type of infusion a resident is receiving (irritant or vesicant), and the location of the IV (placed in an area of flexion such as the antecubital space where more likely to dislodge). New language was added on proper infection control practices when accessing or using IVs. CMS also clarified that facilities should document the reason for keeping an IV when it is no longer being used for fluid or medication.

There are no new requirements in Respiratory Care, F695. However, CMS did clarify that specific guidance related to the care of residents receiving mechanical ventilation only applies to facilities choosing to provide this type of care.

Additions and clarifications were made to Pain Management, F697, specifically related to the use of opioids to address the treatment of resident pain within the context of the current opioid crisis. CMS added definitions for medication assisted treatment (MAT) and opioid use disorder (OUD). MAT is defined as the use of medications, in combination with counseling /behavioral therapies, to treat substance use disorders or OUD. OUD is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress.

The Ftag guidance recommends facility use of the CDC and SAMHSA website for resources on use of opioids in treating chronic pain and opioid management resources for prescribers. Language was added regarding the need for facilities to assess residents for a history of addiction or OUD and related treatments to implement strategies to address pain. These strategies may include MAT, if appropriate, non‐opioid pain medications, and non-pharmacological approaches. Guidance also states that a facility needs to pay attention if there is a pattern of resident reports or has signs/symptoms of increased pain to ensure the problem is not due to drug diversion. Residents need to be monitored for side effects of opioids (tolerance, physical dependance, increased sensitivity to pain, constipation, nausea/vomiting and diarrhea, sleepiness, dizziness, and/or confusion, depression, and itching/sweating), and addresses the prevention of opioid overdoses by administering naloxone. More information can be found in F697.

SNF Questions?
Please email Elena Madrid, or call at 1 (800) 562-6170, ext. 105.