ASSISTED LIVING: AUDITING STAFF FILES IN ASSISTED LIVING

Residential Care Services (RCS) licensors review staff files during a full inspection, as well as during focused complaint investigations and follow-up visits. Recently DSHS updated a form entitled, “Assisted Living Facility Staff Sample/Record Review” (referred to as Attachment K). Licensors use this form to determine assisted living facility compliance with training, testing, and certification regulations. 

This tool, while designed for use by RCS staff, is useful for the assisted living provider to perform internal audits to minimize the likelihood of citations in this area. As the form is filled in, enter “N/A” with any topic that is not applicable to the staff person’s duties.

This article will review all aspects of the Attachment K form and provide insight into how to use this form internally for quality assurance purposes. It will be helpful to print a copy of Attachment K to refer to while reading this article.

Let’s review each area of focus; some explanation for each is provided where necessary. 

NAME. Each staff person’s first and last name.

POSITION. The person’s role. This can be “caregiver” or “RN” or “cook” or similar. There is no need to provide facility-specific titles that may not paint a clear picture of the person’s duties. For example, “Life Enrichment Coordinator” position could be listed as “activities.”

DATE OF HIRE. The date the person was hired. If the person has worked at the facility more than once, indicate the most recent hire date.

DATE OF BIRTH. This is helpful for credentialed staff, to ensure easy look-up on the Department of Health website. 

BGI INITIAL DATE. This is the date the first Name and Date of Birth state background check was completed. This must be started within one day of starting work.

BGI EXPIRE DATE. All Name and Date of Birth state background checks must be completed every two years; they expire exactly two years from the date of completion of the most recent background check.

FINGERPRINT CHECK DATE. Fingerprint checks must be conducted one time only upon hire for all administrators, nurses, and caregivers. The fingerprint background check is initiated just after the results of the initial Name and Date of Birth state background check comes in. This final result must be onsite within 120 days of starting work. WAC 388-78A-24642 (3) allows for an assisted living facility to accept a copy of the national fingerprint background check results letter and any additional information from the department’s background check central unit from the new employee who has previously completed a national fingerprint background check through the department’s background check central unit, provided the national fingerprint background check was completed after January 7, 2012.

CHARACTER, COMPETENCE, AND SUITABILITY EVALUATION. For any staff member whose background check returns with a crime that is nondisqualifying, per WAC 388-78A-24701 the facility must evaluate if and how the crime(s) impact the staff’s abilities to work. This document must be completed and kept in the staff person’s file.

ORIENTATION TO THE FACILITY. All staff exempt from home care aide certification, as well as all volunteers, must have proof of orientation to the facility per WAC 388-112A-0200. WAC 388-112A-0210 (1) outlines required contents of facility orientation. Documentation requirements for facility orientation is outlined in WAC 388-112A-0240.

ORIENTATION AND SAFETY (5 HOURS). This training must be provided for all long term care workers who will become home care aides; this DSHS-approved curriculum must be taught by a DSHS-approved instructor and proof of such documented on a DSHS-issued certificate. Training must be completed before the worker has routine interaction with residents.

70 HOUR BASIC/POPULATION SPECIFIC. This is the home care aide training. If the caregiver was not credentialed as a home care aide (HCA) or nursing assistant certified (NAC) upon hire, the facility must demonstrate completion of training within 120 days of hire. The 70-hour “basic training” is captured on a DSHS-issued certificate that shows completion of all aspects of the home care aide training. Newly hired caregivers who choose to go to nursing assistant training in lieu of home care aide training have the same timeline of 120 days to complete training.

NURSE DELEGATION (ND). If the staff member performs delegated tasks, s/he must have a DSHS-issued 9-hour core nurse delegation certificate on file.

ND INSULIN. If the nursing assistant or home care aide provides insulin injections, s/he must have a DSHS-issued 3-hour “Focus on Diabetes” delegation certificate on file, in addition to the core nurse delegation certificate.

DOH TYPE. If the staff person holds a professional healthcare credential through the Department of Health (DOH), it must be active. List the type of credential in the box – NAC, NAR, HCA, RN, LPN, etc.

EXPIRATION DATE. This is the expiration date of the DOH credential. All caregivers and nurses must keep an active license; for home care aides, they must attest to 12 hours of completed DSHS-approved CE for their credential to be renewed.

SPECIALTY TRAINING. If the facility serves residents with special needs, specialty training must be completed within 120 days of hire for all caregivers, nurses, and administrators (or their designees). Dementia (eight hours), mental health (eight hours), and developmental disability (16 hours) training are the three specialty trainings.

FOOD SAFETY/HANDLER. A food worker card must be earned within 14 days of starting work for any staff member who prepares food. Food worker safety classes are online and count towards one hour of CE for those employees needing continuing education.

12 HOURS CONTINUING EDUCATION. All administrators and caregivers must complete 12 hours of DSHS-approved continuing education each year by the individual’s birthday.

FIRST AID/CPR. All caregivers and the administrator (or designee) need to complete first aid and CPR training within 30 days of starting work and renew regularly. Nurses need CPR training (no first aid) within 30 days of starting work and renew regularly. Washington State does not allow the skills portions of these trainings to be completed online.

TB TESTING. Must be initiated within three days of hire. The IGRA test is a blood test; only one test is required. The TST is a skin test that must be conducted by a doctor or nurse and is done twice (called a “two step”). The facility and/or employee can choose to do either of these two tests.

For the TST, the first test is done within three days of hire and read within 48 to 72 hours from the time of administration. The results are measured in millimeters (mm) of induration. The second TST is started within 1 – 3 weeks of the first test and again read within 48-72 hours.

There are times when only one TST is required: when there is a documented result from a previous two-step skin test done no more than one to three weeks apart, or a documented negative result from one skin or blood test within the previous 12 months.

There are times when no tests are required; see WAC 388-78A-2483 and prepare to have appropriate documentation to support no testing. Likewise, any staff person testing positive to a TST or IGRA test must have a chest X-ray within seven days and documented evaluation of signs and symptoms of tuberculosis.

For questions about assisted living regulations, contact Vicki McNealley via email or call (800) 562-6170 extension 107.

SKILLED NURSING: CONFLICTS OF INTEREST FOR FEDERAL AND STATE EMPLOYEES

Conflicts of Interest for Federal and State Employees

One of the questions that comes up on a routine basis is regarding conflicts of interest related to nursing home surveyors and/or complaint investigators. As you are aware, Residential Care Services (RCS) has several new surveyors either recently completing or undergoing training. It is a catch-22 for facilities; while it is beneficial that these surveyors have some LTC experience, it often comes at the expense of this person leaving work at one of our LTC facilities to work for DSHS. While this staff movement between facilities and the department has occurred for years, it is heightened now due to the extreme staffing crisis facing LTC facilities. The other issue that sometimes arises is that the ex-employee now working for the department may not have left the facility or corporation under the best of terms.

According to CMS, conflicts of interest may arise within a facility when public employees’ duties give them the potential for private gain (monetary or otherwise) or the opportunity to secure unfair advantages for outside associates. The same should be required of state employees whose positions may produce conflicts of interest. This includes all state surveyors and their supervisors. There are several federal and state laws setting forth criminal penalties for abuses of privileged information, abuses of influence, and other abuses of public trust.

Federal employees are required to make a declaration of any outside interests and to update it whenever such interests are identified. CMS states that the same should be required of state employees whose positions may produce conflicts of interest. Both CMS and the state are responsible for evaluating the need for preventive measures to protect the integrity of the NH certification program. CMS also notes that it is not necessary for state agencies such as RCS to inform CMS of all potential conflict situations. However, if an overt abuse requires corrective action, the CMS regional office must be informed. Under federal requirements, any of the following circumstances would disqualify a surveyor from surveying a particular skilled nursing facility or nursing facility:

• The surveyor currently works, or, within the past two years, has worked as an employee, as employment agency staff at the facility, or as an officer, consultant, or agent for the facility to be surveyed.
• The surveyor has any financial interest or any ownership interest in the facility.
• The surveyor has an immediate family member who has a relationship with a facility described above.
• The surveyor has an immediate family member who is a resident in the facility.

Examples of Potential Conflicts of Interest

CMS also notes that they and each state must consider all relevant circumstances that may exist beyond the benchmarks given in the paragraph above to ensure that the integrity of the survey process is preserved. For example, a surveyor may not have worked for the facility to be surveyed for more than two years, but may have left the facility under unpleasant circumstances, or may not currently have an immediate family member who resides there but may have recently had one residing there who the surveyor considers having received inadequate care. CMS goes on to identify that the following are typical of situations that may raise a question of possible conflicts of interest for federal or state employees. However, they do not necessarily constitute conflicts of interest.

• Participation in ownership of a health facility located within the employing state.
• Service as a director or trustee of a health facility.
• Service on a utilization review committee.
• Private acceptance of fees or payments from a health facility or group of health facilities or association of health facility officers for personal appearances, personal services, consultant services, contract services, referral services, or for furnishing supplies to a health facility.
• Participation in a news service disseminating trade information to a segment of the health industry; and
• Having members of one’s immediate family engaged in any of the above activities.

Report and Investigation of Improper Acts

According to CMS, any acts of employees in violation of federal or state laws or regulations regarding conflicts of interest should be managed in accordance with applicable federal or state procedures. States should ask CMS for assistance or advice in the case of any impropriety involving a conflict of interest that cannot be managed immediately under an applicable state procedure. The regional office of the Inspector General, along with the CMS regional office, will then work in close cooperation with the responsible state officials until the matter is resolved.

More information on Washington State laws and ethics can be found in RCW 42.52 Ethics in Public Service and The Washington State Executive Ethics Board.

It is important to note that RCS staff should not be recruiting facility staff while in your facilities. If this occurs, please reach out to your RCS Field Manager. If you have any questions, please email Elena Madrid, Executive Vice President for Regulatory Affairs or call at (800) 562-6170, extension 105.