Desk Review Compliance for Assisted Living Facilities

Presented by the

Texas Health and Human Services

Welcome

Welcome. You have launched Desk Review Compliance for Assisted Living Facilities (ALFs). 

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Background and Purpose

The purpose of this course is to provide guidance to assisted living facility (ALF) staff members and Texas Health and Human Services (HHSC) inspectors on compliance for desk reviews.

For policy/course content questions contact a ALF policy specialist at (512) 438-3161 or email LTCRPolicy@hhs.texas.gov.

Required Materials

To complete this training successfully, you must have access to the ALF regulations, laws and official communications listed below.

To access these materials, click on the titles below. We recommend that you add the URL addresses to your computer's "favorite's list."

1. Texas Administrative Code, Title 26, Chapter 553: Licensing Standard for Assisted Living Facilities
2. Texas Health and Safety Code, Title 4, Chapter 247: Assisted Living Facilities

Course Objectives

Upon completing this CBT, you will be able to:

1. list five criteria for an acceptable plan of correction (PoC); and
2. explain how the decision is made to conduct a desk review.

Outline

This training begins with an overview of the desk review process. Next, we will examine three sample deficiencies individually, including inspector findings, the PoC (Plan of Correction), and a review of how the PoC meets each of the five criteria. Finally, the training concludes with a short quiz.

Overview: Desk Reviews

Desk reviews are the process by which a facility responds to violations that do not directly impact the health and safety of residents may be reviewed. Rather than visiting the facility in person, the review is conducted by mail or telephone. This training describes the procedures for determining when a desk review may be conducted.

HHSC conducts desk reviews for violations that do not require an on-site inspection to determine correction. Through desk review, the region will determine whether the PoCs are acceptable and meet certain criteria. The region may also request evidence from the facility to support that it has achieved and will maintain compliance.

Overview: Desk Reviews (cont.)

Follow-up Inspections

First, let us look at the purpose of follow-up inspections.

HHSC Long-term Care Regulation conducts follow-up inspections of long-term care facilities to determine correction of cited or re-cited violations. Follow-up inspections are routinely conducted on-site; however, they may also be conducted by a desk review.  

Follow-up inspections may include mail or a telephone contact as part of the follow-up.

Overview: Desk Reviews (cont.)

When Does HHSC Conduct a Desk Review?

1. Desk reviews are conducted for violations that do not require an on-site inspection to determine correction where there is no threat to resident health and safety.
2. The decision to conduct a desk review depends on the scope and severity level of the licensure violation(s) cited. This limits on-site revisits to higher level violations and desk reviews to lower level violations. Regional survey staff determine the type of follow-up inspection to conduct using the scope and severity of the violations.
3. Desk reviews do not apply to follow-up inspections after an initial inspection or after a Life Safety Code inspection where there is a potential for a fire safety issue.
4. When violations are cited requiring a desk review and an on-site follow-up inspection, the desk review must be performed first.
5. The desk review may begin when HHSC receives a facility's PoC.

Note: The facility's PoC is written in response to the violations cited on the HHSC Form 3724.

Scope and Severity Levels

Desk reviews are limited to the review of violations cited at levels D through F. Violations cited at level F may be approved for on-site review at the discretion of the regional director (RD).

26 TAC §553.751(d)

Overview: Desk Reviews (cont.)

Notice of Accepted Plan of Correction

During a desk review HHSC may ask a facility to submit documents showing how the facility corrected a particular violation. The documentation must be requested early in the compliance process with the Notice of Accepted Plan of Correction form. This form is used to:

1. notify the facility that its PoC is acceptable and meets the criteria;
2. notify the facility that its PoC may be accepted in lieu of conducting an on-site follow-up inspection; and
3. request evidence from a facility to verify the correction for a particular violation in lieu of conducting an on-site follow-up inspection;

26 TAC §553.331(g)

Overview: Desk Reviews (cont.)

Documents and Records

Additionally, HHSC will request documents and records for:

1. a violation cited with level D through F with a Right to Correct (RTC)/Opportunity to Correct (OTC) that resulted in an administrative penalty recommendation (evidence is requested only for the violation that resulted in the administrative penalty); and
2. a violation cited/re-cited at level D through F with a RTC/OTC during the first or second on-site follow-up visit.

Approval from the regional director (RD) or designee is needed to request evidence for a violation. The facility must submit any additional documentation that is requested.

26 TAC §553.411

Overview: Desk Reviews (cont.)

Documents and Records (cont.)

A facility must maintain compliance after a correction is accepted. If, during a future inspection, corrections to violations that were considered corrected during a desk review are discovered not to have been corrected, or cited again, enforcement action may be recommended.

When concerns about the validity of a facility's reported corrections for a particular violation are not resolved, HHSC conducts an unannounced on-site follow-up inspection. An on-site review is limited to the violation approved for an on-site review by the RD or designee.

Overview: Desk Reviews (cont.)

Acceptable Documentation

Documentation or records must show the action a facility took to correct violations. Examples of acceptable documentation could include:

1. an invoice or receipt verifying purchases were made, repairs were completed, etc.;
2. sign-in sheets verifying staff attendance at in-service trainings;
3. interviews with more than one training participant about the in-service trainings; or
4. a copy of a report (documentation) that indicates corrective action has been completed that includes the signatures of staff members and the dates, etc.

Examples of unacceptable documentation:

• Dating the PoC the same day as the exit date
• Illegible handwriting
• Inadequate proof of monitoring, training, or competency
• Late submissions
• PoCs written on something other than the HHSC form 3724
• Rebuttals/disagreements with findings
• Scanned or emailed documents with confidential information
• Undated PoCs
• Unsigned PoCs

Desk Review Process

Finally, when violations are cited at various scope and severity levels requiring both a desk review and an on-site follow-up visit, the desk review must be performed first.  

The desk review:

1. may begin when HHSC receives a facility's PoC;
2. involves a thorough review of corrections reported on the PoC and/or evidence submitted by the facility, if applicable; and
3. may also involve mail or telephone contact with the facility to obtain clarification about a facility's reported corrections, PoC or evidence.

When HHSC accepts the PoC and the evidence supporting compliance, those documents are accepted as determination of correction in lieu of HHSC conducting an on-site follow-up inspection.

Let's review some guidance regarding submitting an acceptable plan of correction.

Five Criteria for Acceptable Plans of Correction

The facility must submit an acceptable PoC to the Regional Director not later than 10 calendar days after the final exit conference. To be evaluated as acceptable, PoCs must meet the following five criteria:

1. Criterion 1: The PoC must address how corrective action will be accomplished for those residents affected by the violation(s).
2. Criterion 2: The PoC must address how the facility will identify other residents with the potential to be affected by the same violation(s).
3. Criterion 3: The PoC must address the measures or systematic changes the facility will put into place to ensure the violation(s) will not recur.
4. Criterion 4: The PoC must address how the facility will monitor its corrective actions to ensure that the violation(s) are being corrected and will not recur.
5. Criterion 5: The PoC must provide dates when corrective action will be completed.

Examples

In this section, we will review three example deficiencies for an assisted living facility.

In each example, we will:

1. present the deficiency;
2. review sample inspector findings; and
3. look at a sample PoC written for the deficiency and evaluate it using the five criteria for acceptable PoCs.

Example #1: Sample Deficiency

§553.62(c)(2) General Requirements: Operational Features

Fire drills must be conducted quarterly on each shift and with at least one drill conducted each month. The drills may be announced to the residents in advance. The drills must involve the participation of the staff in accordance with the emergency plan. Residents must be informed of the evacuation procedure and locations of exits.

This REQUIREMENT is not met as evidenced by:

Based on record review and interviews, the facility failed to ensure that it met the standards required to maintain fire safety. The facility has failed to conduct monthly fire drills quarterly on each shift. The facility could not provide documentation regarding its quarterly fire drills. This failure creates the potential for the four residents and staff members to be unprepared during a fire emergency, thus putting them at risk in the event of a fire emergency. The facility's census was four.

Example #1: Inspector Findings

The findings for Example #1 were:

A review of the facility's fire drill records on 12/15/20 at 2:45 pm found the documentation regarding monthly fire drills was blank for the past four months. In an interview with the manager on 12/15/20 at 3:40 pm, the manager stated the staff members had not conducted the fire drills because they forgot to do them. The manager stated she had been working at the facility for five months and was not aware of this requirement. In an interview with four staff members (A, B, C and D) on 12/15/20 (at 3:00 pm, 3:10 pm, 3:20 pm and 3:30 pm), two of four (staff members A and D) confirmed that they had not been conducting the fire drills as required. These two staff members worked on the day and evening shifts.

Example #1: Plan of Correction

This is an acceptable sample PoC for Deficiency Example #1. Read it carefully, and then click on each of the blue criterion tab buttons below to see how it meets the five criteria for evaluating acceptable PoCs. It is the responsibility of the participant taking this training to read this information in its entirety.

Facility's Plan of Correction

The facility's manager has completed an in-service on 01/10/21 for all of the staff members regarding conducting monthly fire drills. The fire drills have been conducted on all three shifts. The manager also has made up a schedule for the next year to ensure that at least one fire drill is conducted on each shift because all residents have the potential to be affected. The facility manager will ensure that follow-up in-services will be provided and put the monthly fire drills on his calendar. The manager will check the documentation monthly. The manager will provide in-services quarterly to all staff members and will monitor the fire drill schedule monthly to ensure the fire drills are conducted as required on each shift. A copy of the in-services with staff signatures and dates as well as the fire drill documentation log have been included with this PoC. This was completed on 01/15/21.

Example #2: Sample Deficiency

§553.259(b)(2) Resident Assessment: Service Plan

The service plan must be approved and signed by the resident or a person responsible for the resident's health care decisions. The facility must provide care according to the service plan. The service plan must be updated annually and upon a significant change in condition, based upon an assessment of the resident.

This REQUIREMENT is not met as evidenced by:

Based on record review and interview, the facility failed to ensure that the service plans were updated annually for 2 of 4 residents (Residents #3 and #4).

The failure placed the residents at risk of not receiving appropriate care and services.

Example #2: Inspector Findings

The findings for Example #2 were:

Record review 10/18/20 at 9:30 am for Resident #3's record revealed an admit date of 06/09/18 and the most recent service plan was dated 01/29/19; Resident #4's record revealed an admit date of 10/01/19 and the most recent service plan was dated 04/12/20. More than a year has passed since each has had an update.

Interview with staff A on 10/18/20 at 11:15 am confirmed the fact that the service plans were not up to date and needed to be completed.

Example #2: Plan of Correction

This is a sample PoC for Deficiency Example #2. Read it carefully, and then click on each of the blue criterion tab buttons below to see how it meets the five criteria for evaluating acceptable PoCs. In this PoC, please also see the facility's sample checklist form. It is the responsibility of the participant taking this training to read this information in its entirety.

Facility's Plan of Correction

The manager has reviewed and completed the service plans for residents #s 3 and 4. The manager will review resident #s 1 and 2 records to ensure their service plans are up to date. The facility has developed the attached checklist form which the manager will use to monitor all residents monthly. This will be used for new admits to the facility, any significant changes in residents and when residents are admitted to the hospital. The facility has developed a calendar that indicates the annual due dates for all residents. The assessment service plans have been completed on 11/01/XX. A copy of the service plans and a blank copy of the form developed to track changes have been included with the PoC. This was completed on 11/5/XX.

Example #3: Sample Deficiency

§553.261(e)(4) Dietary Service: Therapeutic Diets

Therapeutic diets as ordered by the resident's physician must be provided according to the service plan. Therapeutic diets which cannot customarily be prepared by a lay person must be calculated by a qualified dietician. Therapeutic diets which can customarily be prepared by a person in a family setting may be served by the assisted living facility.

This REQUIREMENT is not met as evidenced by:

Based on observations, interviews and record review, it was determined that the facility failed to provide 2 of 7 residents (Residents #s 5 and 6) a physician ordered therapeutic diet. Residents #s 5 and 6 were observed to be served foods that were high in potassium for 2 of 2 meals observed. Both residents had kidney disease and could not process extra potassium in their diet. Not adhering to the physician-ordered therapeutic diet could cause problems with kidney disease for residents #s 5 and 6. This could cause the residents who were on therapeutic diets to not receive appropriate nutrition.

Example #3: Inspector Findings

The findings for Example #3 were:

Record review of Resident #5's clinical record revealed an admit date of 04/29/XX with diagnosis of Hypertension, Chronic Kidney Disease and Anemia. Review of the doctor's orders dated 04/27/XX indicated the resident was on a potassium-restricted diet. Record review revealed Resident #6 was admitted to the facility on 05/24/XX with diagnosis of Chronic Kidney Disease, Hypertension and Type II Diabetes. Review of doctor's orders dated 05/24/XX indicated the resident was on a 1800 calorie American Diabetes Association (ADA) and potassium-restricted diet.

Observation of the lunch meal on 10/01/XX at 11:50 am revealed Residents #s 5 and 6 were served taco salad (consisting of tortilla chips, ground beef, lettuce, tomatoes, guacamole and sour cream) with a 8 oz. glass of milk. Observation of lunch meal on 10/02/XX at 11:45 am revealed Residents #s 5 and 6 were served turkey, baked potato, broccoli and a 8 oz. glass of milk. According to the National Kidney Foundation guidelines, milk, tomatoes, avocados, broccoli and potatoes are high in potassium. Interview with the Food Service Director on 10/02/XX at 1:30 pm revealed the facility staff are not trained about therapeutic diets except for diabetic diets (they offer sugar free desserts).

Example #3: Plan of Correction

This is an acceptable sample PoC for Deficiency Example #3. Read it carefully, and then click on each of the blue criterion tab buttons below to see how it meets the five criteria for evaluating acceptable PoCs. It is the responsibility of the participant taking this training to read this information in its entirety.

Facility's Plan of Correction

The manager has reviewed the therapeutic diets and the two residents are being provided the correct diets. The manager has reviewed the diets for all of the residents to ensure they are being provided according to the physician's order. The facility manager has consulted with the dietitian to evaluate the resident diets. The manager will review residents' diets with the dietitian, when residents are admitted and at least monthly. The manager and designee will review all of the residents charts monthly to ensure resident diets are provided as prescribed by the physician. The date of completion is 05/21/XX.

Summary

To achieve and maintain compliance, facility staff must:

1. detect problems;
2. implement solutions or actions to correct the problems; and
3. monitor and evaluate the corrective actions to ensure that the problems will not happen again.

All parts of a PoC must be acceptable:

An acceptable PoC is required for all ALF licensure violations, including physical plant and facility operation requirements. If more than one violation is cited, the PoC for each violation must be acceptable for the overall PoC to be deemed acceptable. All violations must be individually addressed.

Summary (cont.)

Desk reviews involve a thorough review of corrections reported on the PoC and evidence submitted by the facility, if applicable. The desk review may also involve telephone contact with the facility to obtain clarification about a facility's reported corrections, PoC or evidence.

When HHSC accepts the PoC and the evidence supporting compliance, those documents are accepted as determination of correction in lieu of HHSC conducting an on-site follow-up inspection. The correction date for the violation is either the PoC completion date or the date evidence shows the correction was made.

Quiz

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