Long Term Care Facility FAQs

Long Term Care Questions

Q: What is a class AA citation?

A: A class AA citation is a violation that the state department has “determined to have been a direct proximate cause of death of a patient or resident of a long term care facility.” In any action to enforce a class AA citation, the department must prove that the 1) violation was a direct proximate cause of death, and 2) the death resulted from an occurrence of a nature that the regulation was designed to prevent (Health and Safety Code Section 1424(c).

Q: Which facilities may receive a class AA citation?

A: All long term care facilities may receive a class AA citation. The two largest facility categories are skilled nursing facilities and intermediate care facilities for the mentally retarded but also included are congregate health living facilities and pediatric day health respite care facilities.

Q: What is the process used the leads to an AA citation and how are they approved?

A: Most frequently, a class AA citation is based on an investigation of a received complaint or a facility self reported event. In some cases, the violation may be detected during a recertification or licensing survey. Once identified, L&C conducts a thorough investigation using principals of documentation that include record reviews, direct observations and interviews. Once the investigation is completed and the findings written, the report is reviewed by the District Office manager. If the manager concurs that the violation rises to the level of class AA violation, the findings are submitted to a medical consultant, the Department’s Office of Legal Services and the Field Operations Branch Chief for review and approval. If all reviewers concur with the findings, then the District Office issues the citation to the facility.

Q: Is there an appeal process?

A: Yes, the citation can either be appealed to the Department for a Citation Review Conference or appealed directly to court. The outcome of the citation and collection of any fines assessed are not final until all appeals have been exhausted (Health and Safety Code Section 1428(b).

Q: What is the fine for a class AA citations?

A: Health and Safety Code Section 1424.5 (a)(1) dictates that the minimum fine that can be assessed for class AA citation is $25,000 and the maximum fine is $100,000. Facilities that do not wish to contest the level of the citation or the amount of the fine may, within 30 days of issuance of the citation, pay 65% of the assessed fine (Health and Safety Code Sections 1424.5(b).

Q: What will happen to the fine money? Where does it go?

A: All money collected from assessed citations are deposited in the Health Facilities Citation Penalties Account. Funds in this account may be used by the Department to support activities of Temporary Managers appointed by the Department or Receivers appointed by the courts to manage troubled long term care facilities to bring them back into compliance or if necessary to conduct an orderly closure of the facility and safely transfer residents to other licensed facilities. Funds deposited into this account may also be used for quality assurance initiatives that directly improves the health care and services offered to residents (Health and Safety Code Section 1417.2).

Q: Does a facility risk losing its license if it receives a certain number of class AA citations within a certain period of time?

A: Yes, for a second or subsequent class "AA" citation within a 24-month period that has been sustained following a citation review conference, or where the licensee has chosen not to exercise its right to a citation review conference, the Department shall begin action to suspend or revoke the facility's license (Health and Safety Code Section 1424.5(a)(1).

Q: What are the various types of state citations that can be issued?

A: The table below displays the classes of the various state citations as well as the criteria needed to classify the level of the citation.

Class	Facility Type	Definition
AA	LTC	• Meets the definition of a Class “A” violation, and • Was a direct proximate cause of patient death.
A	LTC	• Imminent danger of death or serious harm to patients, or • A substantial probability of death or serious physical harm to patients.
B	LTC	• Has a direct or immediate relationship to patient health, safety, or security. • Can include emotional and financial elements.
Patient Rights B	LTC	• Any violation of patient’s rights as described in Title 22 of the California Code of Regulations (CCR). • A patient’s rights violation produces a situation likely to cause significant humiliation, indignity, anxiety, or other emotional trauma, but is not serious enough to be a Class “A”. • Unless the Department determines that such a violation meets the criteria of a Class “A”.
Abuse Reporting B	LTC	• Failure of the facility to report incidents of alleged or suspected abuse of a facility resident. • Must be reported to the Department immediately or within 24 hours of the incident. • Failure of the facility to meet the requirements in H&S §1418.91 results in a Class “B” citation.
Financial Occurrence Reporting B	SNF	• Failure of the licensee to notify the Department of financial occurrences as described in H&S Code 1421.1. • The Department must be notified within 24 hours of occurrence. • Notification to the Department may be in written form if it is provided by FAX or overnight mail, or • By telephone with a written confirmation within 5 calendar days.
Posting Notice of Imposed Remedies B	LTC	• Facility failure to post notice of remedies imposed for violation(s) of stat or federal requirements as described in H&S Code §1417.15 will result in a Class “B” citation.
Written Notice of Imposed Remedies B	SNF	• Written notification of imposed remedies must be given to the following: each resident, each resident’s responsible party and legal representative and all applicants for admission to the facility. • Facility failure to provide written notice of imposed remedies as described in H&S Code §1429.1 will result in a Class “B” citation.
Posting of Ombudsman Information A & B	SNF	The Department shall assess a civil penalty of one hundred dollars ($100) for each day the facility failures to post the Ombudsman information poster (pursuant to Section 9718 of the Welfare and Institutions Code). • Issued and enforced in the dame manner as a “B” citation: when the penalty is assessed at less than two thousand dollars ($2,000). • Issued and enforced in the same manner as a “A” citation: when the assessed penalty is equal to or in excess of two thousand dollars ($2,000).
Willful Material Falsification (WMF)	LTC	Any entry in the health care record that falsely reflects the condition/care/services provided to the resident, such as: • Administration of medication or treatments ordered. • Services pertaining to the prevention or treatment of pressure sores or contractures. • Tests and measurements of vital signs. • Notations of input and output of fluids.
Retaliation/ Discrimination	LTC	Prohibits licensee from discriminating or retaliating against: • Patient • Employee • Any other person who has presented a grievance/complaint, or has initiated/cooperated in any investigation/preceding of any governmental entity relating to care/services/conditions.
C (written as state deficiencies)	LTC	The violation at the time of the occurrence has minimal (remote) relationship to patient health, safety or security.
Willful Material Omission (WMO)	LTC	• Willful failure to record any untoward event which has affected the health, safety, or security of a patient, and • Was omitted with the knowledge that the record falsely reflects the condition of the patient or care or services provided.
Family Council B	SNF	• Facility may not prohibit the formation of a family council. • Facility may not limit the function of the family council. • Failure of the facility to meet the requirements of H&S Code §1418.4 results in a Class “B” citation.

Q: How do I interpret the severity of a deficient practice that is cited in a federal recertification survey?

A: The “scope and severity” of a federal deficiency is assessed based on how egregious the violation was (“A” being minimal and “L” the most severe) and how widespread was the problem in terms of affected residents (i.e., isolated, pattern, or widespread). The scope and severity classification only relates to skilled nursing facilities. The grid below provides a visual display of the scope and severity classification.

There are four severity levels.

Level 1 (A, B, C) is a deficiency that has the potential for causing no more than a minor negative impact on the resident(s). No actual harm with potential for minimal harm.

Level 2 (D, E, F) is noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident’s ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. No actual harm with potential for more than minimal harm that is not immediate jeopardy.

Level 3 (G, H, I) is noncompliance that results in a negative outcome that has compromised the resident’s ability to maintain and/or reach his/her highest practicable physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. This does not include a deficient practice that only could or has caused limited consequence to the resident. Actual harm that is not immediate jeopardy.

Level 4 (J, K, L) is immediate jeopardy, a situation in which immediate corrective action is necessary because the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility (see Appendix Q).

There are three scope levels: isolated; pattern; and widespread.

Scope is isolated (A, D, G, J) when one or a very limited number of residents are affected and/or one or a very limited number of staff are involved, and/or the situation has occurred only occasionally or in a very limited number of locations.

Scope is a pattern (B, E, H, K) when more than a very limited number of residents are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same resident(s) have been affected by repeated occurrences of the same deficient practice. The effect of the deficient practice is not found to be pervasive throughout the facility.

Scope is widespread (C, F, I, L) when the problems causing the deficiencies are pervasive in the facility and/or represent systemic failure that affected or has the potential to affect a large portion or all of the facility’s residents. Widespread scope refers to the entire facility population, not a subset of residents or one unit of a facility. In addition, widespread scope may be identified if a systemic failure in the facility (e.g., failure to maintain food at safe temperatures) would be likely to affect a large number of residents and is, therefore, pervasive in the facility.

LEVEL 4	Immediate Jeopardy To Resident Health Or Safety	LEVEL 4, ISOLATED J	LEVEL 4, PATTERN K	LEVEL 4, WIDESPREAD L
LEVEL 3	Actual Harm That Is Not Immediate Jeopardy	LEVEL 3, ISOLATED G	LEVEL 3, PATTERN H	LEVEL 3, WIDESPREAD I
LEVEL 2	No Actual Harm With Potential For More Than Minimal Harm That Is Not Immediate Jeopardy	LEVEL 2, ISOLATED D	LEVEL 2, PATTERN E	LEVEL 2, WIDESPREAD F
LEVEL 1	No Actual Harm With Potential For Minimal Harm	LEVEL 1, ISOLATED A	LEVEL 1, PATTERN B	LEVEL 1, WIDESPREAD C