Part of the full inspection process in assisted living communities involves the licensors observing resident care. The purpose of these observations is multi-layered and includes assurances that:
  • The resident receives appropriate care based on needs;
  • Care provided is consistent with the negotiated service agreement;
  • Services are provided by qualified, trained caregivers;
  • The resident’s rights are honored, including quality of life, dignity, privacy, and choice.

The most defensible citations are formed through, first and foremost, observations. While formal and informal observations take place throughout the full inspection, the process of observing resident care is formal in nature. Additional data may be collected through interview and/or record review to support or invalidate the observations.

Informal observations may include the following, but is not limited to these areas:
  • Resident person hygiene (oral hygiene, grooming, body odor, nail and hair care, clean/appropriate clothing
  • Visible skin conditions (rashes or bruising for example)
  • Behavioral challenges, level of cognition
  • Level of mobility; independence or assistive devices needed/used; condition of assistive devices
  • Potential restraint usage
  • Level of assistance with dining
  • Appropriate footwear for safety and comfort

Formal care observations may include personal care (activities of daily living) and/or provision of intermittent nursing services. Special focus will likely take place regarding staff-to-resident interactions, staff knowledge and skill, and infection control practices. Only RN licensors can observe personal care that reveals a resident’s genitals or breasts.

The licensor will ensure the resident or, in the event a resident is unable to consent, the legal surrogate decision maker agrees to the observation. If the resident refuses a licensor’s observation, the licensor will choose another resident to observe. Additionally, the licensor will not examine nor touch the resident during these observations.

It is imperative that caregivers and nurses know the residents well and honor their wishes while providing safe care following best practices. The negotiated service agreement should remain up-to-date and serve as a primary resource for caregivers when determining the level of assistance a resident needs. Competency-based training can accomplish this goal through routine and just-in-time observations and prompt follow-up to ensure care and services meet expectations.

If you have questions about the full licensing inspection process, or other topics related to assisted living, please email Vicki McNealley or call her at (800) 562-6170 extension 107.
Denial of Payment for New Admissions (DPNA) is often confused with the state of Washington’s enforcement remedy, Stop Placement. It is important to understand the difference between state remedies and the Federal enforcement actions. While a state Stop Placement can pertain to all residents regardless of payer type, a federal DPNA generally applies to Medicare/Medicaid.

This remedy may, and in certain instances, must, be imposed by CMS or the State Agency (SA). DPNA may be imposed alone or in combination with other remedies to encourage quick compliance. Formal notice of the imposition and rescission of this remedy may also be provided by the state. 

This remedy may be imposed anytime a facility is found to be out of substantial compliance if the facility is given written notice at least two calendar days before the effective date in immediate jeopardy situations and at least 15 calendar days before the effective date in non-immediate jeopardy situations. 

CMS will accomplish the denial of payment remedy through instructions to the appropriate Medicare Area Contractor. Regardless of any other remedies that may be imposed, DPNA must be imposed when the facility is not in substantial compliance three months after the last day of the survey identifying deficiencies, or when a facility has been found to have furnished substandard quality of care on the last three consecutive standard surveys. 

Generally, if the facility achieves substantial compliance and it is verified, CMS or the SA must resume payments to the facility prospectively from the date it determines that substantial compliance was achieved. However, when payment is denied for repeated instances of substandard quality of care, the remedy may not be lifted until the facility is in substantial compliance and the state or CMS believes that the facility will remain in substantial compliance. No payments are made to reimburse the facility for the period between the date the remedy was imposed and the date that substantial compliance was achieved. 

CMS may impose the DPNA remedy whenever a facility has not met a requirement; it is a severe sanction. Factors to be considered in selecting this remedy could include: 
  1. Seriousness of current survey findings. 
  2. Noncompliance history of facility; and 
  3. Use of other remedies that have failed to achieve or sustain compliance.

If you have questions regarding state or federal enforcement remedies for skilled nursing facilities, 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