Q&A Response from RCS-AFH Provider Forum 5/17/2023

Many of you had questions for RCS leadership during the May 2023 RCS-AFH Provider Forum. Here are the answers to your questions.

Q1. What is the definition of imminent harm that would require a QIP to call the hotline? We are mandated reporters required to report abuse, neglect, exploitation & abandonment per RCW 74.34.  Imminent harm is not the measurement of reportable events reportable to CRU.

Q2. What is the water temperature to be?  WAC 388-76-10750(6)(a)(b)(c) requires adult family homes to ensure hot water temperature is at least one hundred five degrees and does not exceed one hundred twenty degrees Fahrenheit at all fixtures used by or accessible to residents, such as tubs, showers, and sinks.

Q3. Is there a free fit testing agency? There is not a free fit testing agency. The Department of Health (DOH) will train you or someone at your home to conduct fit testing.  Please look on the DOH Fit Testing Training website for training dates and information.  You may also look on the DOH Respiratory Protection Program (RPP) for Long-Term Care Facilities website for other ways DOH can and will support your RPP. You can contact DOH Occupational Health Team at HAI-FitTest@doh.wa.gov for questions.

Q4. If we get an error on TB testing and learned about it later and fixed the problem, do we still get cited? What happened was some confusion with the two step process.  Depends on the fact pattern. If recognized later and fixed before an inspection or investigation, and have documented test results and readings, that would be evidence of compliance.

Q5. Will we get the slides? RCS shares the forum slide deck with the AFH Council who posts it on their website.

Q6 How often do we do fingerprints? Is it routine every 2 years?

WAC 388-76 requires the following:

Background checks—Washington state name and date of birth background check—Valid for two years—National fingerprint background check—Valid indefinitely.

(1) A Washington state name and date of birth background check is valid for two years from the initial date it is conducted. The adult family home must ensure:

(a) A new DSHS background authorization form is submitted to the department’s background check central unit every two years for each individual listed in WAC 388-76-10161;

(b) There is a valid Washington state background check for all individuals listed in WAC 388-76-10161.

(2) A national fingerprint background check is valid for an indefinite period of time. The adult family home must ensure there is a valid national fingerprint background check for individuals hired after January 7, 2012 as caregivers, entity representatives or resident managers. To be considered valid, the individual must have completed the national fingerprint background check through the background check central unit after January 7, 2012.

 Q7. How do we contact the Behavioral Support Team (BHT)? Can we get the material for reading?  To contact the BHT for a consultation, providers can email the Behavioral Health Team at RCSBHST@dshs.wa.gov.  To get information about trainings, they can email at ALTSABHSTTraining@dshs.wa.gov . They also can view more information about our the team on BHT website Behavioral Health Support for Providers | DSHS (wa.gov).

Q8. Where can we get the supplies and equipment for protection? Does a specialist come to fit a N95? What is the cost?

  • FIT TEST KITS & SUPPLIES: You can purchase fit test kits over the internet.  DOH recommends that you purchase a qualitative fit testing kit with either bitter or sweet solution. Here is a link to Fit Test Kit and Hood Options for information on the fit test kits including how to find them on the internet. The DOH Fit Testing Training website lists the other supplies you will need for fit testing (such as mirror, clock with second hand, hand sanitizer, and more).
  • FIT TEST TRAINING: A DOH specialist will train you or someone to conduct fit testing for your home. Please see the DOH Fit Testing Training website for all the information you need to know to get someone trained as a fit tester.  There is work that must be done before you are trained to fit test and virtual support (not in person – over the phone or internet) once you have the fit tester training.
  • RESPIRATOR SUPPLIES: To get N95 respirators, the DOH Frequently Asked Questions (FAQ) will tell you – Where can we get more N95s?
  • COST: The DOH training is free. Fit Test Kits can range from $50 to $300 in the open market.  One fit test kit can be used to fit test many staff for a long time.  You can pay to have mobile fit testers come to your home for a fee per person, usually $50 to $75 each.  You can send your staff to a local occupational health clinic for fit testing. The cost is $75 – $100 or more.  PLEASE NOTE:  Before your staff can be fit tested, they must have required training and medical clearance approval to wear an N95 respirator. Medical clearance is an additional charge.
    • It can be done at the occupational health clinic with fit testing or on-line with a service.
    • DOH will cover the cost of on-line medical evaluations for a limited time. To enroll your employees in no-cost online respirator medical evaluations, please send the following information to HAI-FitTest@doh.wa.gov:
          Facility/agency name, address, and facility DSHS license number
      •    Contact person, email address, and phone number
      •    Estimated number of employees requiring medical evaluation at your facility/agency
      •    Include **MEDICAL EVALUATION** in the subject line

Q9. Is a SOD the same as a citation?   A SOD (Statement of Deficiency), the official, publicly disclosable document describing the entity’s noncompliance with regulatory requirements for AFHs. Included in the SOD statement the entity signs and dates indicating the projected correction date of the cited deficient practice. The SOD is a legal document available to the public on request.  The SOD contains deficiency statements of non compliance. A deficiency citation is documentation of a violation of statute or regulation, other than those defined as a consultation. A deficiency citation consists of: The applicable State of Washington Administrative Code (WAC) and/or the applicable Revised Code of Washington (RCW), the language from that reference, which pinpoints the aspects(s) of the requirement with which the provider is in non compliance, an explicit statement that the requirement was “not met”, and the evidence to support the decision of noncompliance.

Q10. Is there another day for this webinar?  The May forum will not be repeated.  The AFH Council has it posted on its website so providers can listen to it when able.  These questions will be posted on the website as well.

Q11. When you are invited for an early visit, how much does the QIP charge? The LTC QIP visits are free.

Q12. Can the QIP come back to reassess if called? The LTC QIP Specialist will do a virtual follow-up visit at 4 to 6 months.

Q13.  Let us know early to be available for the next forum.  The PowerPoint presentation from the May 17, 2023 has the next upcoming forum dates for the rest of 2023.  The Dear Provider letter announces the 2023 forum schedules: ALTSA: AFH #2023-012 RESIDENTIAL CARE SERVICES & ASSOCIATION PROVIDER FORUMS, @ https://www.dshs.wa.gov/sites/default/files/ALTSA/rcs/documents/multiple/Provider%20Forum%202023%20Schedule.pdf

Q14. Should we expect to receive a real inspection shortly after we access the QIP service? No, there is no coordination between LTC QIP visits and regulatory visits. LTC QIP visits are non-regulatory and are intended to educate and support providers with resources to be used in their daily operations. The LTC QIP team does not coordinate or report to the regulatory arm of RCS.

 Q15. Does the QIP notify RCS of the name of the AFH that was visited? Name, date and area?  After a visit, the LTC QIP Specialist only sends the RCS Field Manager the name of the provider, the visit date and the protocol area completed during the visit. All information obtained during the visit is confidential and is not shared with anyone other than the LTC QIP Team members. A general email will be sent to the field manager to let them know that the home received a visit and that no reportable concerns (abuse, neglect, abandonment, exploitation) were identified. All LTC QIP visits are confidential, records are kept in a separate filing system that regulatory staff does not have access to.

Q16. When admitting new residents, do they still need a negative COVID test within 48 of admission?  No. There is no state or federal requirement for residents to have a negative COVID-19 test within 48 hours of admission to an Adult Family Home.  You may ask for COVID-19 testing before admission as a business practice if you wish. 

Q17. Is it requirement to print out everything and file in binders?  I use Synkwise for eMARS, uploading care plans, assessments, policies, etc.  It is not required to print out everything in a binder if you, your staff, and RCS staff have access to your electronic record.   Residents/representatives must have access to the record on request. 

Q18. How can we schedule an appointment for a QIP visit?  Requests for a LTC QIP visit can be made by emailing the LTC QIP at RCSQIP@dshs.wa.gov Emails will be answered within 2 business days by a LTC QIP Specialist discussing the program and possible dates for the initiation of a visit.

We may say we can answer questions about the program and are prepared to schedule a visit if the provider is ready to do so.

Q19. Are you sending us notes?  RCS shares the forum slide deck with the AFH Council who posts it on their website.

Q20. How often do we need to keep fingerprints for current working staff? Refer to question 6 for AFH WAC 388-76-10165 requirements for fingerprints. A National fingerprint background check—Valid indefinitely.

Q21. What if employees left? Do we have to keep their credentials?  If so for how long in the AFH?  For a positive blood TB test and Chest X-ray? For a positive blood TB test & negative X-ray?  WAC 388-76-10310 requires the adult family home to retain staff records the records for eighteen months after the date an employee either quits or is terminated, including any documented history WAC 388-76-10275 requires when staff have previous positive tests.

Section 388-76-10310 – Tuberculosis – Test records

Universal Citation: WA Admin Code 388-76-10310

Current through Register Vol. 23-06, March 15, 2023

The adult family home must:

(1) Keep the records of tuberculin test results, reports of X-ray findings, and any physician or public health provider orders in the adult family home;

(2) Make the records readily available to the appropriate health authority and licensing agency;

(3) Provide the employee a copy of his/her testing results; and

(4) Retain the records for eighteen months after the date an employee either quits or is terminated.

Section 388-76-10275 – Tuberculosis – No testing

Universal Citation: WA Admin Code 388-76-10275

Current through Register Vol. 23-06, March 15, 2023

The adult family home is not required to have a person tested for tuberculosis if the person has:

(1) A documented history of a previous positive skin test, with ten or more millimeters induration;

(2) A documented history of a previous positive blood test; or

(3) Documented evidence of:

(a) Adequate therapy for active disease; or

(b) Completion of treatment for latent tuberculosis infection preventive therapy.

There is a form to fill out for Signs and Symptoms Evaluation. The form provided by the AFHC says this:
“For applicants with a positive TST (TB Skin Test), they will need to have a health care professional (MD, ARNP, RN, LPN) complete this form.”


I was told that there are providers being cited for not having an MD filling out the form.  Is an RN still able to fill out this form? Please verify if what the AFHC form has is correct.  There is no specific form.  Providers can use forms to document the WAC 388-76-10290 requirements and may choose to use the AFHC form for staff evaluations. This WAC requires Adult Family homes to ensure staff with + tests have a C-Xray within 7 days, their health care provider evaluates them for TB signs and symptoms, and staff their provider’s recommendations. Staff health care providers would document the evaluations and prescribe the Chest X-rays.  It is up to the staff health care entity who completes and signs the evaluation.  One entity may have a physician and another a nurse.

Section 388-76-10290 – Tuberculosis – Positive test result

Universal Citation: WA Admin Code 388-76-10290

Current through Register Vol. 23-06, March 15, 2023

When there is a positive result to tuberculosis skin or blood testing the adult family home must:

(1) Ensure that the person has a chest X ray within seven days;

(2) Ensure each resident or employee with a positive test result is evaluated for signs and symptoms of tuberculosis; and

(3) Follow the recommendation of the person’s health care provider.

 Q22. Will the inspector focus more on the subjects that the QIP tells them they focused on for the AFH? An inspector will focus on areas of reported or observed care practices. There is no correlation between LTC QIP visits and Inspections.  All LTC QIP visits are confidential and non-regulatory however, all providers are expected to be in compliance with all applicable laws and rules at all times.

Q23. Is there a way to reach out to the RCS team? I see there are names but no phone numbers or e-mail addresses.  Even going online and doing a Google search, I wasn’t able to find contact info for the field managers.   Can it be made available?  RCS office directories are located on the Aging and Long-Term Support Administration Long Term Care Professional and Provider website.  Click on “contact us” and you will find information for HQ and Region 1, 2, and 3.  Website: Residential Care Services | DSHS (wa.gov)

Q24. Are background checks for over 11 yrs. old mean once they turn 11 or once they are older than 11, meaning when they turn 12?  Over the age eleven is 12 years old or greater.

WAC 388-76-10161(3) requires:

Background checks—Who is required to have.

(3) All household members over the age of eleven, volunteers, students, and non-caregiving staff who may have unsupervised access to residents must have a Washington state name and date of birth background check. They are not required to have a national fingerprint background check.

Q25. The way citations are written, makes it sound like you almost killed the resident prevention and protection.  Can the wording be less aggressive? More on tone with the severity of the citation?  (When there is a small mistake that hasn’t caused any harm and isn’t that dire but is a mistake.)  We appreciate the feedback and will share it with our Director.

Q26. Are any of the field managers from an AFH background? How many have worked in an AFH or ran an AFH before becoming inspectors? Just trying to gauge how well they understand our work and what they are asking of us.   Many of our managers have promoted internally and have been licensors and complaint investigators regulating residential care settings so they are familiar with adult family homes and the adult family home program.  Those recruited outside of the division have worked with community settings and partners.

Q27. What do we do with expired masks?  Does it make sense for them to expire?
What exactly expires? As I understand, it’s the elastic…which some of them break anyways when new. If it breaks you replace it. So not sure why the expiration if the filtration is still good.  
NIOSH (National Institute for Occupational Safety and Health) does not set expiration dates.  Expiration dates are set by manufacturers (companies who make masks).  The reason for expiration date is that a mask’s effectiveness depends on having a good fit. If the elastic straps, nose pieces and other structures degrade over time, the masks may fit less well. There are not enough studies to show that expired masks work the same or as well as unexpired masks.  You can find out from the manufacturer if the expiration date has been extended. For example, BYD DE2322 respirator shelf life is extended to 2025. 

Q28. Why don’t hospitals discharge to Adult Family Homes? (When residents are ready to be discharged.)  I remember when hospitals were full and part of the reason was because they couldn’t discharge patients to LTC. But there were many providers that had vacancies & couldn’t find residents.  Is there a way to inform hospitals about AFH option for LTC? Or what was the reason?

Q29. Adult Family Homes should get some kind of award or benefits for being so far ahead of all other types of long-term care when it came to Covid infections & deaths.  RCS appreciates the service Adult Family Homes provided citizens the last three years in a pandemic.  We will share your feedback with our Director.

Q30. How do we know if we are protected by the vaccine or if it’s just our immune system?  The variants since Omicron have been milder symptoms when infected.  We’ve learned that the way the vaccine works is by making the symptoms less severe (Not preventing it completely as we originally thought at first.)  So if the symptoms from the current variant is identical to the symptoms of vaccinated people, what does that mean?  

There are two factors at work here.  One factor is the seriousness of the COVID-19 virus. The other factor is the ability of the body to fight infection.  I will talk about this then answer the questions.

  • COVID-19 Virus. Viruses mutate over time. The Coronavirus variant today is less deadly than the initial, Delta and first Omicron variants.  Even so, COVID-19 remains a virus that can and does cause death and disease.  Some say COVID-19 is as at least as deadly as the flu, which kills 50,000 people per year.  If the COVID-19 virus is as deadly as the flu, then that means that 50,000 people could die from COVID-19 in a year.
  • Immune Status. COVID-19 is very serious for people over 65 and people who are immunocompromised – those who get very sick easily because their body cannot fight infection as well as healthy people.  People who are healthy may be able to fight off the COVID-19 virus without vaccines.  This is not the case for persons 65 and older and for the immunocompromised.
  • How do we know if we are protected by the vaccine or if it’s just our immune system? Vaccines boost the body’s natural immunity – ability to fight off the virus.  Getting vaccinated helps you not be as ill if you get the virus. If you received the vaccine (and especially boosters) and you get COVID-19, then your body had help fighting the infection.  Your body recognized the virus and had an army of soldiers (blood cells) ready to fight and defend your body from illness. If you did not receive the vaccine, your body had to fight the infection without help.

If the symptom from the current variant is identical to the symptoms of vaccinated people, what does that mean?  This means that the virus is less deadly now in 2023 than in 2020 but can still make people sick and die.  Vaccinated people still may get sick, but not as sick as if they did not have the vaccine. COVID-19 is much more easily spread than the flu. Vaccines help prevent the disease from spreading to those the virus might kill or make very ill. 

Q31.  Should we be looking at implementing programs like Synkwise since things are going more and more electronic?  There is no department requirement for the specific program Synkwise. 

Q32.  If there are some discrepancies QIP finds, will providers receive a citation?  No, providers do not receive a citation when gaps are found. When the LTC QIP Specialist identifies system gaps the provider is given free technical assistance to improve the system(s).

The LTC QIP visits are non-regulatory. This program was implemented to support providers in their care of residents to prevent harm and negative outcome, and to promote compliance with applicable laws and rules.


Q33. What is a 90-day supervision check documentation? RND?  WAC 246-840-930? What is required to become a nurse delegator in State of WA is according to the law RCW 18.79.260 and regulations WAC 246-840-910 to 970 written by the Nursing Commission. Subsections (18) and (19) under WAC 246-840-930 explain the 90 day requirement for time requirements to reevaluate and document services and evaluate nursing assistant performance. 

WAC 246-840-930

Criteria for delegation.

(1) Before delegating a nursing task, the registered nurse delegator decides the task is appropriate to delegate based on the elements of the nursing process: ASSESS, PLAN, IMPLEMENT, EVALUATE.


(2) The setting allows delegation because it is a community-based care setting as defined by RCW 18.79.260 (3)(e)(i) or an in-home care setting as defined by RCW 18.79.260 (3)(e)(ii).

(3) Assess the patient’s nursing care needs and determine the patient’s condition is stable and predictable. A patient may be stable and predictable with an order for sliding scale insulin or terminal condition.

(4) Determine the task to be delegated is within the delegating nurse’s area of responsibility.

(5) Determine the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. The registered nurse delegator assesses the potential risk of harm for the individual patient.

(6) Analyze the complexity of the nursing task and determine the required training or additional training needed by the nursing assistant or home care aide to competently accomplish the task. The registered nurse delegator identifies and facilitates any additional training of the nursing assistant or home care aide needed prior to delegation. The registered nurse delegator ensures the task to be delegated can be properly and safely performed by the nursing assistant or home care aide.

(7) Assess the level of interaction required. Consider language or cultural diversity affecting communication or the ability to accomplish the task and to facilitate the interaction.

(8) Verify that the nursing assistant or home care aide:

(a) Is currently registered or certified as a nursing assistant or home care aide in Washington state without restriction;

(b) Has completed both the basic caregiver training and core delegation training before performing any delegated task;

(c) Has evidence as required by the department of social and health services of successful completion of nurse delegation core training;

(d) Has evidence as required by the department of social and health services of successful completion of nurse delegation special focus on diabetes training when providing insulin injections to a diabetic client; and

(e) Is willing and able to perform the task in the absence of direct or immediate nurse supervision and accept responsibility for their actions.

(9) Assess the ability of the nursing assistant or home care aide to competently perform the delegated nursing task in the absence of direct or immediate nurse supervision.

(10) If the registered nurse delegator determines delegation is appropriate, the nurse:

(a) Discusses the delegation process with the patient or authorized representative, including the level of training of the nursing assistant or home care aide delivering care.

(b) Obtains written consent. The patient, or authorized representative, must give written, consent to the delegation process under chapter 7.70 RCW. Documented verbal consent of patient or authorized representative may be acceptable if written consent is obtained within 30 days; electronic consent is an acceptable format. Written consent is only necessary at the initial use of the nurse delegation process for each patient and is not necessary for task additions or changes or if a different nurse, nursing assistant, or home care aide will be participating in the process.


(11) Document in the patient’s record the rationale for delegating or not delegating nursing tasks.

(12) Provide specific, written delegation instructions to the nursing assistant or home care aide with a copy maintained in the patient’s record that includes:

(a) The rationale for delegating the nursing task;

(b) The delegated nursing task is specific to one patient and is not transferable to another patient;

(c) The delegated nursing task is specific to one nursing assistant or one home care aide and is not transferable to another nursing assistant or home care aide;

(d) The nature of the condition requiring treatment and purpose of the delegated nursing task;

(e) A clear description of the procedure or steps to follow to perform the task;

(f) The predictable outcomes of the nursing task and how to effectively deal with them;

(g) The risks of the treatment;

(h) The interactions of prescribed medications;

(i) How to observe and report side effects, complications, or unexpected outcomes and appropriate actions to deal with them, including specific parameters for notifying the registered nurse delegator, health care provider, or emergency services;

(j) The action to take in situations where medications and/or treatments and/or procedures are altered by health care provider orders, including:

(i) How to notify the registered nurse delegator of the change;

(ii) The process the registered nurse delegator uses to obtain verification from the health care provider of the change in the medical order; and

(iii) The process to notify the nursing assistant or home care aide of whether administration of the medication or performance of the procedure and/or treatment is delegated or not;

(k) How to document the task in the patient’s record;

(l) Document teaching done and a return demonstration, or other method for verification of competency; and

(m) Supervision shall occur at least every 90 days. With delegation of insulin injections, the supervision occurs at least weekly for the first four weeks, and may be more frequent.

(13) The administration of medications may be delegated at the discretion of the registered nurse delegator, including insulin injections. Any other injection (intramuscular, intradermal, subcutaneous, intraosseous, intravenous, or otherwise) is prohibited. The registered nurse delegator provides to the nursing assistant or home care aide written directions specific to an individual patient.


(14) Delegation requires the registered nurse delegator teach the nursing assistant or home care aide how to perform the task, including return demonstration or other method of verification of competency as determined by the registered nurse delegator.

(15) The registered nurse delegator is accountable and responsible for the delegated nursing task. The registered nurse delegator monitors the performance of the task(s) to assure compliance with established standards of practice, policies and procedures and appropriate documentation of the task(s).


(16) The registered nurse delegator evaluates the patient’s responses to the delegated nursing care and to any modification of the nursing components of the patient’s plan of care.

(17) The registered nurse delegator supervises and evaluates the performance of the nursing assistant or home care aide, including direct observation or other method of verification of competency of the nursing assistant or home care aide. The registered nurse delegator reevaluates the patient’s condition, the care provided to the patient, the capability of the nursing assistant or home care aide, the outcome of the task, and any problems.

(18) The registered nurse delegator ensures safe and effective services are provided. Reevaluation and documentation occur at least every 90 days. Frequency of supervision is at the discretion of the registered nurse delegator and may be more often based upon nursing assessment.

(19) The registered nurse must supervise and evaluate the performance of the nursing assistant or home care aide with delegated insulin injection authority at least weekly for the first four weeks. After the first four weeks the supervision shall occur at least every 90 days.

Q34.  Why do QIPs notify RCS? The LTC QIP is a unit within RCS.  RCS Field Managers are notified so RCS staff know who has made a provider visit.

Q35. So for the e-fax, RCS will send to provider fax? Or will it be sent via email? My fax machine is not that great so does that mean we have to buy new fax machines? 

The Statement of Deficiency (SOD) will be sent by eFax. If your fax machine is not that good, RCS can also send the document by email or paper.  The eFax receipt date is used to decide when your plan of correction or attestation is due. The quickest way for you to get a good quality SOD is to have it emailed to you in addition to eFax. 

Q36. How do I know what Unit my AFH is in?  Refer to Question 23 how to look the name, office, and telephone #s for Field Managers for locations and county oversight.  The county will tell you what unit location.

Q37. Please clarify if QIP program is looking at reported issues or to prevent an issue? Referrals can be made to the LTC QIP if there is identified noncompliance and citations, as well as to identify gaps within a provider’s system to prevent harm and negative outcomes to residents, and to help promote compliance. The LTC QIPs are free technical assistance to prevent and improve specific systems, such as Medication Systems, Fall Systems and Infection Prevention Systems.

Q38. Will the department increase the number of training sessions for AFH Orientation class?  There are 70 classes per year throughout the state; on average seven classes per month. RCS is at capacity of offering classes and has no plans to add classes for now.

Q39. Didn’t get exactly what was said about background checks for 11 yr. old related to citations.  Refer to Question 24.

Q40. How long is a fingerprint check good for?  Refer to Question 24.