LeadingAge WA and other stakeholders met with Mike Anbesse, Director Residential Care Services, as a follow up to our conversation in February regarding survey culture in WA State. 

As you may recall, LeadingAge WA started this work in January 2020, with our Survey Summit.  In January 2021, we requested a meeting with the new Director of RCS in the hopes of influencing his role as leader through honest and transparent discussion about the brokenness of survey including the culture or attitude of certain surveyors and field managers.  We invited other stakeholders including the Adult Family Home Council, Supportive Living and WHCA to sign on to our Four Pillars ~ Bold Leadership document and join us in this important conversation with Mike and Bill Moss.

The meeting today with Mike was positive and encouraging.  We believe he heard our concerns and has been making changes at the RCS regional survey level to begin to address them.  Bill Moss and Mike Anbesse have been on a “listening tour” around the state and have met with skilled nursing and assisted living providers in Regions 1 and 2 and have appointments with providers in Region 3. They intend to next hear from adult family homes and supportive living agencies.  The intent is to continue these listening tours to hear from additional providers in each of the provider types.

Highlights of this morning’s meeting are as follows:

• Communication – RCS conducted communications training with all surveyors in April prior to restarting the survey process.  Emphasis was placed on how the surveyors present themselves and the perception providers of have of them.  Surveyors have a history of being perceived as difficult to work with, the “experts” of how things should be done, and at time, as bullies.  The training focused on communicating with providers as equal partners in resident care.  This training was reviewed by LeadingAge WA, WHCA, the AFHC and Supportive Living clinicians prior to it being presented to the surveyors.  
• Citations – Several providers brought up staffing during the listening tours, such as, why are we being given citations for staffing when we are doing everything possible to hire or bring in agency staff but are unable to find staff.  Consequently, Mike explained to surveyors that if providers are doing everything they can do to hire staff, using agency as available, and trying to make it work, perhaps citing for lack of staffing should not occur.  Instead, the focus will be outcomes and resident care.  Also, providers will not be cited for using contingency or crisis standards for PPE.  The FDA and CDC have stated providers should be back in conventional strategy for PPE use, however, Mike disagrees and understands the need to continue to conserve PPE in anticipation of flu and a surge in virus.  Use of contingency PPE should not rise to the level of a citation.
• Consistency in Enforcement – Several providers were able to explain to Mike and Bill how the inconsistency in citation scope and severity and enforcement from region to region is happening. Administrators who have worked in other regions of the state were also able to give examples of these inconsistencies across the state.  RCS has begun having monthly Field Manager calls to discuss why a citation is or is not called as an IJ for example so there is shared learning.  Enforcement findings are also discussed in an effort to improve consistency in the remedial action taken by RCS. Compliance Specialists are also available to check surveyor’s documentation and intended citations as a guard against issuing citations that cannot be supported and, therefore, should not be cited.
• Quarterly Meetings with Providers – The quarterly meetings for SNF and AL providers with RCS staff have been going well. The recordings and Q & A documents are sent out following the meeting.  The goal of these meetings is to help providers feel comfortable with asking Field Managers and Regional Administrators questions about the survey process and the regulations. One topic that has been frequently raised is when to report incidents to CRU and the inconsistency in reporting expectations.  In the RCS meetings, it has been stated that if a provider can rule out abuse or neglect these incidents do not need to be called in, yet surveyors are still citing for not calling the incidents in.  Mike agrees that there is wide variation in reporting and reflected on his days working as a DNS in a skilled nursing facility and his own frustration.  Reporting of these incidents will be addressed at the next quarterly meeting with all providers (tentatively set in December).
• Training Unit – The RCS training unit will soon be adding 8 FTEs and will have regional training units for RCS survey staff.  These training units will use adult learning principles. This will be an internal QA process for RCS surveyors.  They will also be adding a QI team to the training unit. Trainers will shadow surveyors for immediate, “just in time” assessment of practices and correction as needed.  These positions have yet to be filled but we will keep you apprised once they are, and the program is implemented.
• QAN Program – RCS is reinstituting the QAN program for LTCF.  This has been a LeadingAge WA priority.  There will be six QANs initially and they will be managed by someone other than the Field Managers.  This will be a separate unit and information learned through the consultation process with providers will not be shared with Field Managers or surveyors and QANs will not be used as surveyors.  They will prioritize homes with enforcement actions to receive QAN visits first. This is very good news!
• Survey – It was acknowledged that the hybrid survey model that was implemented with the restart of full surveys is not working well. Mike shared that the process was not well through from start to finish for all settings and that this new process is particularly clunky for adult family homes and supportive living. Surveyors will be in the buildings to do record reviews and interviews again.  We also pointed out the excessiveness of both the number of surveyors and the time spent in buildings and encouraged further consideration of the necessity of this approach.
• Complaint Investigations – Mike attended a national conference and learned about the reporting of complaints in other states and found WA state can make improvements here by requiring fewer facility generated incident reports. Publicly generated incident reports will be separated and treated as a complaint.  However, if the facility has generated a report, and had a plan of correction in place by the time of the call, Mike’s thinking is that these should not be included as complaints and they should, therefore, not be investigated as a complaint. RCS will be having ongoing discussions about this and determining whether legislation or a change in WAC will be needed to implement this change.  Mike noted that separating out facility generated complaints should reduce both CRU and provider burden on staff resources.  In the meantime, continue to report as required.
• Change of Ownership Applications – These applications were being held up if there was any pending enforcement on other communities owned/operated by the same entity. This process has been discarded and BAAU has been informed not to delay the processing of these applications based on pending enforcement actions.

At our request, the meetings with Mike, RCS Director, and the associations will continue every other month so we can continue to inform Mike about what we are hearing from members – both improvements and any continuing concerns, and he can share with us his ongoing work to change the culture, improve consistency across regions and ensure fairness and accuracy in citation and enforcement decisions.  We will continue to update you on progress with our collaborative work to improve you experience with the survey process, interactions with surveyors as well as outcomes

Questions?

Contact:

Laura Hofmann, MSN, RN – Director of Clinical and Nursing Facility Regulatory Services
c: 425-231-4804