Frequently Asked Questions - D-E-F

Title 22, §87758

A Type A violation is considered the most serious type of deficiency.  It is described as a deficiency that "poses an immediate or substantial threat to the health, safety and/or rights of the residents if not corrected".  Examples cited in Title 22  "include, but are not limited to", the following issues:

  • Criminal record clearances
  • Fire clearances
  • Night supervision
  • Food service, storage and preparation
  • Limitations on number, types and/or ambulatory status of residents
  • Telephone service
  • Health conditions of residents (bedridden, prohibited conditions, communicable diseases)
  • Resident rights
  • Safety of accommodations
  • Use of restraints 
  • Medical and dental care of residents
  • Medication
  • Water temperature
  • Hygiene accommodations (bathrooms, etc)
  • Relocation orders

During CARR's file review and review of the regulations, we've noticed that facilities receiving a Type A citation receive no other consequence than to create and adhere to a plan of correction. 

Title 22 authorizes LPAs to issue a penalty of $50 per day (maximum up to $150), per cited violation only if the violation is not corrected by the date specified in the plan of correction.  Based on CARR's file review, this practice is rare.  Very often there was no documentation of any follow-up visits to verify if the corrections had taken place.  More common, the file contained a faxed transmittal or mailed-in letter of self-certifying through receipts, photographs or letters of promise that the corrections had been made. CCLD also provides a LIC 9098 allowing a Licensee to self-certify that corrections have been made; with a self-certification in hand, the LPA is saved a return trip to the facility to validate the correction has been made. 

Of the Type A citations listed above, it appears violations of criminal record clearances most consistently resulted in civil penalties ($100/day).  For all other common Type A citations, civil penalties were rarely, if ever assessed.

CARR suggests consumers be watchful for repeated citations for violation of the same regulation - from one inspection to the next.  These patterns should be discussed to your satisfaction with the Licensee if you are considering the facility for placement of your resident. 

Reasons for Evaluations

  • All RCFEs subject to unannounced visits by CCLD.
  • Required inspections are once every 3 years, as of 2017.  
  • Special circumstances (i.e. probationary license, etc) may require more frequent visits.
  • CCLD is required to visit facilities as often as necessary to ensure quality care is provided.
  • CCLD shall conduct annual unannounced visits to no less than 20% of facilities.
  • Visits for complaint investigations are different than visits for facility evaluations. 

Facility evaluations are reported on LIC 809s.

Reasons for Deficiencies

A deficiency is defined by Title 22 as "any failure to comply with any provision of the act governing RCFEs and any other applicable regulations". 

If a deficiency is found during an evaluation, LPAs are required to issue a notice of deficiency.  However, if the deficiency is deemed minor and is corrected during the visit a notice of deficiency need not be issued according to Title 22. 

If a deficiency is noted, the LPA must meet with the person in charge of the facility and discuss the noted deficiencies and together they must develop a plan for correcting each deficiency.  The plan of correction must then be included on the notice of deficiency.  The notice is then signed by both parties and should then be posted in a conspicuous location in the facility.

Viewing deficiencies

Copies of all notices of deficiencies are kept at the facility (as well as at CCLD in the facility's individual file). 

Every RCFE must:

According to Title 22, §87101(d)(2), "deficiency" ". . . means any failure to comply with any provision of the Residential Care Facilities Act for the Elderly and regulations adopted by the Department pursuant to the Act."

Title 22, §87101(e)(6) "exception" ". . .means a variance from a specific regulation based on the unique need or circumstances of a specific resident or staff person."  An exception cannot be transferred or applied to any other individual.  Requests for exceptions are made to CCLD by the Licensee.

Title 22, §87101(d)(4) defines "dementia" to mean ". . . the loss of intellectual function (such as thinking, remembering, reasoning, exercising judgment and making decisions) and other cognitive functions, sufficient to interfere with an individual's ability to perform activities of daily living or to carry out social or occupational activities.  Dementia is not a disease itself, but rather a group of symptoms that may accompany certain conditions or diseases, including Alzheimer's Disease.  Symptoms may include changes in personality, mood and/or behavior.  Dementia is irreversible when caused by disease or injury, but may be reversible when caused by depression, drugs, alcohol, or hormone/vitamin imbalances."

 

 There is a regulatory difference between Licensees providing care of residents with dementia (Title 22, Section 87705), and Licensees who "advertise, promote, or otherwise hold themselves out as providing special care, programming and/or environments for residents with dementia (Title 22, Section 87706).  Also, not all facilities are approved by the state to provide dementia care;  CARR's review of 354 files revealed that Licenses (LIC 203) issued by CCLD frequently do not state whether a facility provides Dementia care.  If it is unclear from the License whether Dementia care is provided, the consumer should ask for clarification. 

The state once required Dementia waivers before Licensees could care for residents with dementia; Dementia Waivers are no longer required.  

 

Title 22 §87628 & 87629

Diabetes is an on-going medical condition and without proper management can result in serious medical complications.  RCFEs are licensed as non-medical facilities and are not required to have on staff a licensed skilled professional.  Therefore, the consumer should know what is legally allowed within the RCFE setting  regarding diabetes care, and compare that to the current and potential needs of the resident.

Facilities are allowed to accept or retain a resident who has diabetes if:

(1) the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication (which includes both oral and injections)

(2) or if the resident has the medication administered by an appropriately skilled professional.

If the resident is able to manage her condition independently, then there is no need to read further.  If the resident requires assistance in managing her diabetes and there is a skilled professional (i.e. an RN) on-staff available 24/7 to assist, then you will want to be sure there is good communication between yourself/the resident, the skilled professional and other staff members.  If the resident requires assistance in managing her diabetes, and there is not a skilled professional on staff and readily available, then review the remainder of this FAQ to review that placement in such a facility will meet the resident's specific needs.

Injections

Regarding injections, unless they are a licensed skilled professional, staff cannot mix medication, fill a syringe, nor can they administer injections. 

Facilities are charged with the responsibility of ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility. 

Facilities must also ensure that syringes and needles are disposed of properly (per California Code of Regulations, Title 8, §5193 & Title 22 § 87303(f)(2). 

Managing diabetes is not simply medication management; proper diet and sufficient physical activity are important as well.  Title 22, §87628 states that the facility is responsible for providing modified diets as prescribed by a resident's physician. Discuss with the facility its ability  to consistently accommodate dietary needs.  Deviations from established/pre-approved menus are known to occur in some facilities.  Equally important: double-check that the physical activities scheduled on the facility's activities calendar are sufficient and actually take place.

Contact the LPA assigned to the facility if you have concerns regarding your diabetic resident; in many cases, facility personnel are unclear as to what they are allowed and not allowed, to do.   

If you experience unlicensed personnel performing functions reserved for skilled professionals, report the incident to CCLD immediately.  LPAs are required to issue a notice of deficiency to the facility immediately, citing Regulations §87629(a) and (b)(1),  and §87465 (a)(6),  per CCLD's Evaluators Manual.

Title 22, §87101(d)(9), a "Do-Not-Resuscitate" or DNR Form ". . . means the pre-hospital do-not-resuscitate forms developed by the California Emergency Medical Services Authority. . ."  [and others.]  "These forms, when properly completed by the resident or (in certain instances) a resident's Health Care Surrogate Decision Maker and, by a physician, alert pre-hospital emergency medical services personnel to the resident's wish to forego resuscitative measures in the event of the resident's cardiac or respiratory arrest."

Review the resident's file to validate the resident's signed DNR is in the file, and verify the facility knows its responsibility to immediately provide the DNR to emergency responders

Title 22 §87465

The regulations read:

"When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility."

CCLD (or the Department) makes Form LIC 622 available to facilities on its website.  This form is designated as The Centrally Stored Medication and Destruction Record.

Most larger facilities have 'corporate' policies and procedures in place to record centrally stored medications.  Some smaller facilities have them in place as well.  However, there is no explicit declaration in the facility's public file as to whether or not they record such information, or if they meet the criteria requiring central storage.

Assuming that precise information regarding a resident's medications is being recorded is not valid.  In CARR's experience, we have seen documentation of facilities using shoe boxes as storage units, with post-it notes serving as official documentation for the next shift, or other insufficient techniques.  We have also seen incomplete and inconsistent use of LIC 622s.   Asking questions and being vigilant with regard to a facilities' centrally stored medication policies and procedures is consumers best way to obtain confidence in how the facility manages medications.

As defined by Title 22, §87101(e)(1), an "egress alert device" means ". . . a wrist band or other device which may be worn by a resident or carried on a resident's person, which triggers a visual or auditory alarm when the resident leaves the facility building or grounds."

Title 22 Section 87209 - Program Flexibility

Under this section of Title 22, a Licensee can submit a request for a written exception to retain a resident who has a prohibited or restricted health condition, and would otherwise have to move to a higher level of care.

Per Title 22, §87101(f)(2), "Federal Bureau of Investigation (FBI) clearance" ". . . means an individual has no felony or misdemeanor convictions reported by the Federal Bureau of Investigation.  The individual may also have been arrested with no criminal conviction, convicted of a minor traffic offense or adjudicated as a juvenile."

Receiving an FBI clearance is a component of receiving a Criminal Record Clearance, required for Licensees, employees, volunteers, and other individuals (who are not residents) residing in the facility, prior to having a presence in the facility.

(Title 22, §87202)

  • Prior to accepting any residents, the licensee must notify CCLD and obtain an appropriate fire clearance for the clients the RCFE plans to serve.
  • All facilities must maintain an appropriate fire clearance approved by the fire department having jurisdiction over the area the facility is located in.   

The request (STD 850) for Fire Marshal Clearance (FMC) is forwarded to the local Fire Marshal Office, or Fire Protection Jurisdiction.  The agency then schedules a tour of the facility, and notes any approvals or special conditions on the body of the STD 850.  The completed document is signed by the agency and returned to CCLD for its action.  Fire clearances are required for non-ambulatory, hospice and bedridden resident acceptance and retention. 
 

Title 22 §87756

Reasons for Evaluations

  • All RCFEs subject to unannounced visits by CCLD.
  • Inspections are required every three years, as of 2017.  
  • Special circumstances (i.e. probationary license, etc) may require more frequent visits.
  • CCLD is required to visit facilities as often as necessary to ensure quality care is provided.
  • CCLD shall conduct annual unannounced visits to no less than 20% of facilities.
  • Visits for complaint investigations are different than visits for facility evaluations. 

Facility evaluations are reported on LIC 809s.

Reasons for Deficiencies

A deficiency is defined by Title 22 as "any failure to comply with any provision of the act governing RCFEs and any other applicable regulations". 

If a deficiency is found during an evaluation, LPAs are required to issue a notice of deficiency.  However, if the deficiency is deemed minor and is corrected during the visit a notice of deficiency need not be issued according to Title 22. 

If a deficiency is noted, the LPA must meet with the person in charge of the facility and discuss the noted deficiencies and together they must develop a plan for correcting each deficiency.  The plan of correction must then be included on the notice of deficiency.  The notice is then signed by both parties and should then be posted in a conspicuous location in the facility.

Viewing deficiencies

Copies of all notices of deficiencies are kept at the facility (as well as at CCLD in the facility's individual file). 

Every RCFE must: