Layceann Phillips-Russell
Synkwise Compliance Manager
Former Adult Family Home Provider
No provider opens an Adult Family Home with the goal of receiving a deficiency.Yet every year, Adult Family Home (AFH) providers across Washington receive citations during inspections.
After years of owning and operating Adult Family Homes, one thing became very clear to me:
Most deficiencies don’t happen because providers don’t care. They happen because systems break down. Documentation gets missed. An assessment or care plan isn’t completed on time. An employee or resident file is incomplete, or a process that usually works has fallen through the cracks.
The good news is that many of the most common deficiencies are preventable when providers understand what surveyors are looking for and build systems to support compliance.
According to the Washington Department of Social and Health Services (DSHS) 2025 Q4 citation report, annual license fees, resident rights notices, medication systems, and personnel records were among the most frequently cited regulations.
Let’s look at ten common deficiency areas and what providers can do to stay ahead of them.
1. Medication Systems
Medication-related citations consistently appear among the most common deficiencies.
Surveyors want to see:
- Accurate medication records
- Current medication orders
- Proper medication storage
- Documentation of medication refusals
- Consistent medication administration practices
Provider Tip:
Don’t wait for survey season to audit your medication system. Conduct routine internal audits throughout the year.
For additional guidance, our article on medication orders in assisted living covers what to check before orders reach the medication administration record (MAR).
2. Personnel Records
Caregiver files are often among the first things surveyors review.
Common issues include:
- Missing training records
- Expired certifications
- Incomplete personnel files
- Missing documentation of required screenings and background checks
Provider Tip:
Create a monthly personnel file audit process rather than reviewing files only when a survey is approaching.
3. Resident Record Content
Resident records tell the story of the care being provided.
Surveyors are looking for:
- Current assessments
- Accurate care plans
- Updated contact information
- Complete documentation
Provider Tip:
If someone unfamiliar with the resident reviewed the record today, would they clearly understand the resident’s needs?
4. Negotiated Care Plan Reviews
Care plans should be living documents.
One of the most common mistakes providers make is allowing care plans to become outdated.
In Washington, negotiated care plans must be completed within 30 days of admission and reviewed at least every 12 months. Changes in a resident’s needs or certain requests may also require a review.
Surveyors want to see:
- Timely reviews
- Updates following significant changes
- Resident involvement and family involvement when appropriate and approved by the resident
Provider Tip:
Tie care plan reviews to existing workflows so they don’t become an afterthought.
5. Resident Rights
Resident rights are a foundational part of quality care.
Surveyors may review:
- Privacy practices
- Grievance processes
- Choice and autonomy
- Resident dignity
- Required notices and acknowledgments
Washington also requires homes to provide a written notice of rights and services before admission. The notice must be reviewed, with a signed acknowledgment, at least every 24 months.
Provider Tip:
Ask yourself: Are we protecting resident rights in practice, not just on paper?
6. Safety and Maintenance
Providers sometimes become so focused on care that environmental issues get overlooked.
Surveyors often review:
- Building safety
- Maintenance concerns
- Environmental hazards
- Emergency exits
Provider Tip:
Walk your home regularly as if you were seeing it for the first time.
7. Medical Devices
Equipment must be properly maintained and used to support resident safety.
Examples include:
- Oxygen equipment
- Mobility devices
- Specialized care equipment
For medical devices with known safety risks, Washington also requires an assessment and documentation of the device’s use in the resident’s negotiated care plan.
Provider Tip:
Ensure staff understands both the purpose and proper use of resident equipment.
8. TB Testing and Health Requirements
Personnel health requirements remain a common citation area.
Surveyors may review:
- Tuberculosis (TB) testing documentation
- Employee health records
- Compliance with required screenings
Washington requires TB testing for specified Adult Family Home personnel within three days of employment, with additional requirements depending on the testing method and circumstances.
Provider Tip:
Make TB testing part of your employee onboarding checklist. Keep the required documentation organized so it’s easy to locate when needed.
9. Emergency Evacuation Drills
Emergency preparedness is more than a binder on a shelf. Surveyors want evidence that staff knows what to do during an emergency.
Under Washington’s current evacuation drill requirements, Adult Family Homes must conduct partial evacuation drills at least every two months during random staffing shifts and a full evacuation drill at least once each calendar year.
Each resident must participate in at least one partial drill per year, and all residents must participate together in the annual full drill, subject to their right to refuse. Homes must also keep required drill records and follow the additional requirements when a resident refuses to participate.
Provider Tip:
Ask your staff how they would respond to various emergency scenarios. Their answers can quickly identify gaps in preparedness.
10. License and Administrative Requirements
Administrative requirements may seem simple, but they still generate deficiencies.
In fact, annual license fees were the most frequently cited individual regulation in Washington DSHS’s 2025 Q4 report.
Under Washington’s licensing requirements, the annual license fee is due during the same month the home was originally licensed.
Deadlines matter.
Required documentation matters.
Timely updates matter.
Provider Tip:
Create a compliance calendar for important deadlines and recurring requirements.
Frequently Asked Questions About Washington AFH Inspections
What are the most common DSHS survey deficiencies for Washington Adult Family Homes?
According to Washington DSHS’s 2025 Q4 citation report, annual license fees, resident rights notices, medication systems, and personnel records were among the most frequently cited individual regulations.
Other commonly cited areas include medical devices, safety and maintenance, resident records, and negotiated care plans.
How can Adult Family Home providers prepare for a DSHS inspection?
Start by reviewing your medication systems, resident records, negotiated care plans, personnel files, safety practices, and emergency preparedness.
Regular internal audits and consistent documentation can help identify missing information before it becomes a bigger issue.
What These Deficiencies Have in Common
What’s interesting about this list is that many of these deficiencies aren’t about caring less.
Most are system failures.
That’s why I believe the strongest Adult Family Homes focus on more than compliance.
They focus on building systems that support residents, families, caregivers, and providers.
When systems are strong, compliance becomes easier.
When compliance becomes easier, providers can spend more time focusing on what matters most: caring for people.
Build Stronger Systems for Your Adult Family Home
Keeping up with medication records, care plans, and daily documentation takes a lot of work.
Synkwise helps Adult Family Home providers keep important information organized in one place, making it easier to manage daily responsibilities, support caregivers, and stay inspection ready.
See how Synkwise can support your home’s day-to-day operations.
Disclaimer: This article is for general educational purposes and does not replace current Washington DSHS guidance or applicable regulations. Survey findings depend on individual circumstances, and requirements may change. The ten sections above represent common deficiency areas rather than a ranking of the ten most frequently cited individual regulations.
