Post on 11-Sep-2021
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
“STATE OF ASSISTED LIVING – CY 2014”
March 31, 2015
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Agenda 1. Organizational Chart/ Regional office locations
2. Trends and Statistics
AL Capacity
Affiliation/Ownership Trends
AL Complaints
AL Self-Reports
AL Post-Survey Results
AL Survey
Abbreviated Surveys
AL Enforcement
3. WCCEAL
4. Bureau of Assisted Living Strategies
5. Regulatory Stories
6. Wrap up
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living
Regulatory Goal
Using existing statutes, rules, and agency
resources--and through collaboration with
stakeholders--promote the development of
effective systems (e.g., procedures, trained
workforce, effective care plans, etc.) in
regulated communities.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Org. Chart BAL
Alfred C. Johnson Dir.
NERO Kathy Lyons, ALRD
8 surveyors 2 support staff
WRO Bill Gardner, ALRD
7 surveyors 2 support staff
SRO Paul Peshek, ALRD
8 surveyors 2 support staff
SERO Susan Farmer, ALRD
8 surveyors
2 support staff
2 QAPS 1 Research Tech. 1 Office Operations
Associate (50%)
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Western Regional Office
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Southern Regional Office
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL South Eastern Regional
Office
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL
North Eastern
Regional
Office
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Central Office
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living
Regional Assignments
SERO • Kenosha, Milwaukee, Racine
NERO
• Adams, Brown, Calumet, Door, Fond du Lac, Green Lake, Kewaunee, Manitowoc, Marinette, Marquette, Menominee, Oconto, Outagamie, Ozaukee, Portage, Shawano, Sheboygan, Washington, Waushara, Waupaca, Winnebago, Wood
SRO • Columbia, Crawford, Dane, Dodge, Grant, Green, Iowa, Jefferson, Lafayette, Richland, Rock, Sauk,
Walworth, Waukesha
WRO
• Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Clark, Douglas, Dunn, Eau Claire, Florence, Forest, Iron, Jackson, Juneau, Langlade, La Crosse, Lincoln, Marathon, Monroe, Oneida, Pepin, Pierce, Polk, Price, Rusk, Sawyer, St. Croix, Taylor, Trempealeau, Vernon, Vilas, Washburn
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Assisted Living
Communities
• DHS 88
• Ch. 50
• DHS 89
• CH. 50
• DHS 83
• Ch. 50
• Adult Day Standards
Adult Day Care
Community Based
Residential Facility
Adult Family Home
Residential Care
Apartment Complexes
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Trends & Statistics
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Population Changes
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Population Changes
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services Assisted Living Trends
Provider Growth:
Largest growth in AFH
Complaints:
Complaints have increased
Citations:
Citations have increased
Severity:
Serious Violations have increased
Pro
vid
er
Gro
wth
Co
mp
lain
ts
Seri
ou
s v
iola
tio
n
Cita
tion
s
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Nursing Home & FID
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
FIDs 37 35 32 22 19 16 14 14 13 13 12 10
NHs 407 404 404 403 402 399 399 399 400 397 399 395
0
50
100
150
200
250
300
350
400
450
Trend in Number of Facilities
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Nursing Home & FID
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
FIDs 2391 2115 1734 1354 1190 1102 989 939 908 768 720 577
NHs 40661 39959 39276 38700 38106 37494 36557 36022 35661 34992 34639 33886
0
5000
10000
15000
20000
25000
30000
35000
40000
45000Trend in Capacity for Residents
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Assisted Living
36th Consecutive Year of Growth!!
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Communities
0
1000
2000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
RCAC 152 171 188 203 218 245 271 278 295 303 308 313
AFH 765 834 965 1049 1130 1185 1273 1392 1467 1544 1621 1759
CBRF 1352 1367 1372 1382 1403 1429 1458 1470 1476 1501 1514 1522
Nu
mb
er
of
Co
mm
un
itie
s
Trend in Number of Communities
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Capacity
0
10000
20000
30000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
AFH 2964 3217 3727 4054 4358 4585 4916 5430 5730 5987 6285 6815
RCAC 6055 6614 8003 8980 9562 10579 11988 12330 13176 13580 14069 14338
CBRF 21392 21739 21996 22408 22822 23490 24366 24765 25201 25985 26750 27597
Cap
acit
y
Trend in Assisted Living Capacity
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
AL vs. LTC Facilities
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
AL 2269 2372 2525 2634 2751 2859 3001 3238 3348 3348 3577 3727
LTC 444 439 436 425 421 415 413 413 413 410 411 405
0
500
1000
1500
2000
2500
3000
3500
4000
Nu
mb
er
of
Faci
liti
es
Trend in Number of Facilities
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
AL vs. LTC Capacity
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
LTC 43052 42074 41010 40054 39296 38596 37546 36961 36569 35760 35359 34463
AL 30411 31570 33726 35442 36742 38654 41270 42525 44107 45552 51158 52719
0
10000
20000
30000
40000
50000
60000
Cap
aci
ty
Trend in Capacity for Residents
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Residential Care Apartment Complex
0
100
200
300
400
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Certified 86 94 104 115 125 147 174 184 196 204 210 220
Registered 67 77 84 88 93 100 97 94 99 99 98 93
Total 153 171 188 203 218 247 271 278 295 303 308 313
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Adult Day Care Centers
0
20
40
60
80
100
120
140
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
ADC 101 105 106 97 102 114 115 121 128 134 134 133
Trend in Number of Centers
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Adult Day Care Centers
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014ADC 2526 2578 2582 2617 2770 3101 3097 3407 3471 3874 4054 3969
Trend in the Capacity for Participants
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ownership by Count ALL
CY 2014 1%
31%
17%
1% 0% 0%
38%
2% 9%
0% 1%
CHURCH
CORPORATION - BUSINESS
CORPORATION - NONPROFIT
GOVERNMENT - COUNTY
GOVERNMENT - STATE
GOVERNMENT - OTHER
LIMITED LIABILITY COMPANY
PARTNERSHIP
PROPRIETORSHIP
TRIBAL
OTHER
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ownership-ADC
CY 2014
8
30
44
8 1
14
4
2
24 CHURCH
CORPORATION - BUSINESS
CORPORATION - NONPROFIT
GOVERNMENT - COUNTY
GOVERNMENT - OTHER
LIMITED LIABILITY COMPANY
OTHER
PARTNERSHIP
PROPRIETORSHIP
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ownership-AFH
CY 2014 6
578
211
8 1
593
22 62
279
CHURCH
CORPORATION - BUSINESS
CORPORATION - NONPROFIT
GOVERNMENT - COUNTY
GOVERNMENT - STATE
LIMITED LIABILITY COMPANY
OTHER
PARTNERSHIP
PROPRIETORSHIP
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ownership-CBRF
CY 2014 17
500
295
15 7 1
647
4 9
35
4
CHURCH
CORPORATION - BUSINESS
CORPORATION - NON PROFIT
GOVERNMENT - COUNTY
GOVERNMENT - OTHER
GOIVERNMENT - STATE
LIMITED LIABILITY COMPANY
OTHER
PARTNERSHIP
PROPRIETORSHIP
TRIBAL
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ownership-RCAC
CY 2014
14
51
87
5 3
149
2 2 2
CHURCH
CORPORATION - BUSINESS
CORPORATION - NON PROFIT
GOVERNMENT - COUNTY
GOVERNMENT - OTHER
LIMITED LIABILITY COMPANY
OTHER
PARTNERSHIP
PROPRIETORSHIP
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Communities by
Affiliation CY 2014
0200400600800
10001200140016001800
ADC AFH CBRF RCACIndependent 67 422 163 39
Affiliated 66 1337 1359 274
Nu
mb
er o
f C
om
mu
nit
ies
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
New AL vs. Closed AL
0
50
100
150
200
250
300
350
400
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014new 247 322 352 321 282 296 350 315 363 328 361
closed 223 243 323 293 279 245 357 279 337 315 332
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Why Facilities Closed
CY 2014
24%
31% 8%
4%
14%
9%
2% 8%
Voluntary
CHOW
Withdrew App.
Location Change
Conversion
Non renewal
Revoke/Deny
Inactive
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Complaints
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
ASSISTED LIVING COMPLAINTS
RECEIVED
0
100
200
300
400
500
600
700
800
900
1000
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
# complaints 792 667 677 718 681 774 836 789 801 916 900 981
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Complaints vs. Growth
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
# complaints 792 667 677 718 681 774 836 789 801 916 900 981
# AL Facilities 2370 2477 2631 2731 2853 2973 3117 3261 3366 3482 3577 3727
0
500
1000
1500
2000
2500
3000
3500
4000
2003- 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Complaints Received
CY 2014
10
187
670
113
ADC
AFH
CBRF
RCAC
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Percent of Facilities Making up a
Percent of Complaints
0
10
20
30
40
50
60
70
80
90
100
25% 50% 75% 100%
2.5 6.4 8.3 10.2
% of Facilities % of Complaints
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Source of Complaint
CY 2014
33%
11% 21%
11%
10%
4% 5% 3% 2%
Anonymous
Public Official
Relative/Guardian
Current Employee
Former Employee
Medical
Citizen
Resident
Advocate
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Ranking – Subject Areas of Complaint
Investigations
2008 2009 2010 2011 2012 2013 2014 Administration 2 1 1 2 2 2 1 Medications 1 3 3 3 3 3 4 Resident Rights 3 2 2 1 1 1 2 Program
Services 4 4 4 5 5 4 3
Nutrition &
Food 6 6 8 4 4 7 8
Staff Adequacy 5 8 6 7 7 8 6 Supervision 8 5 5 8 8 6 5 Staff Training 9 7 7 6 6 5 7
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2008 2009 2010 2011 2012 2013 2014 Abuse 7 9 11 12 12 12 11 Homelike
environment 10 10 10 10 10 9 14 Physical Plant &
Hazards 13 11 12 11 11 11 12 Res. Behavior/
Facility practice 11 13 13 13 13 10 13
Quality of Life
12 12 9 9 9 13 9 Admission/
Discharge 14 14 14 14 14 14 10 License capacity or
class 15 15 15 15 15 15 15 Restraints
16 16 16 16 16 16 16
Ranking – Subject Areas of Complaint
Investigations
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Source % rec. & Inv. % substantiated Anonymous 33 25 Public Official 11 49 Relative/Guardian 21 40 Current Employee 11 31 Former Employee 10 26 Advocate 02 68 Citizen 05 29 Medical 04 41 Resident 04 23 100% 43%
Source of Complaint vs. Substantiation
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Self-Reports
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Self-Reports Received
0
500
1000
1500
2000
2500
3000
3500
4000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
1166 1452
1856 1872
2751
3446 3271
3534 3343
3645
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Self-Reports Received
CY 2014 (3,645)
324 26
3284
Open Investigation
Review next visit
File
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Number of Self-Reports by
Subject Area CY 2014
1976
278
294
258
408
255 43
47 12 26 8 3
Falls
Res. Behavior
Police
Elopement
Hospital (not fall)
Other
Misappropriation
Abuse
Neglect
Fire
Comm. Disease
Disaster/Evacuation
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
268
20
Self-Reports Investigated - CY
2014 (288)
No SOD
SOD
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Post-Survey
Results
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Post-Survey Questionnaire
2014 - 54 respondents
Satisfaction with survey tasks
94.41 %
On Site - 4.62
• Knowledgeable - 4.75
• Professional - 4.71
• Respectful - 4.73
SOD – 4.22
1 = strongly disagree,
5 = strongly agree
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living
Standard/Abbreviated Survey Process
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Survey Processes
• Unannounced
• Standard surveys (2 year cycle)
• Abbreviated surveys
o No substantiated complaints
o No enforcement x 3 years
o Licensed at least 3 years
• Complaint investigations
• Verification Visits
• Initial Licensing/Certification
• Self-Report investigations
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Standard Survey
• An outcome-based survey that focuses on
the quality of life and care provided by
assisted living communities
• Interviews, observations, record review
• Obtain input from consumers, family
members, advocates, and staff to evaluate
compliance, systems, and outcomes
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Key Code (Core Areas)
• Consumer Rights
• Provision of Services / Quality of Care
• Nutrition and Food Service
• Physical Environment & Safety
• Staff Training
• Medication Management
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Survey Results
No deficiencies
Notice of Finding
Statement of deficiency
Statement of deficiency with
enforcement
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Provider’s Plan of Correction
• What corrective action and system changes will be
made to ensure violations are corrected and
regulatory compliance is maintained?
• Who is responsible for monitoring for continued
regulatory compliance?
• Department Orders, if applicable. Submit
documentation, if requested.
• Date of completion for each corrective action
(Violation, Order).
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Stakeholder Collaboration
• Sharing Statements of Deficiency (SOD)
• Posting SODs, enforcement notices, profiles
• Referrals (OCQ, DSPS, OIG, Human
Service Agencies, Case Managers,
Departments of Justice, Fraud)
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Regulatory
Activity CY 2014
• Standard Surveys 533
• Initial Surveys 371
• Abbreviated 287
• Other (Enf. VV & Complaint) 1321
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Abbreviated Surveys
CY 2014
• No Deficiency Survey - 66%
• Statement of Deficiency - 33%
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Facilities Qualifying for
Abbreviated Surveys – CY 2014
• Adult Day Care 61.2%
• Adult Family Homes 48.8%
• Community Based Residential Facility 45.8%
• Residential Care Apartment Complex 52.8%
• Statewide 49.1%
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Facilities Qualifying for an
Abbreviated Survey
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014Abbrev. 37.20 37.90 38.20 40.50 39.30 42.40 45.70 46.70 46.80 50.80 53.50 49.10
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Survey Results – Statewide
0%10%20%30%40%50%60%70%
No Cites SOD OnlySurveys w/ Enf2007 62% 15% 23%
2008 63% 15% 22%
2009 61% 16% 23%
2010 63% 12% 25%
2011 63% 15% 22%
2012 65% 14% 21%
2013 65% 14% 21%
2014 excludesinitial/CHOW
55% 11% 33%
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Total Cites 2421 2625 2569 2759 2369 2417 2623 2471 2420 2091 2423
Avg Per Cite 3.3 3.3 3.7 3.3 3 2.9 3.4 3.6 3.3 3.2 2.5
0
0.5
1
1.5
2
2.5
3
3.5
4
0
500
1000
1500
2000
2500
3000
Assisted Living Citations
Issued
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
CBRF Top Ten Citations CY 14
01020304050607080
NUMBER OF CITATIONS
ENTITY SANCTION (4 YEAR CBC) 80
SERVICE PLANS UP ANNUALLY OR ON CHANGES 55
FIRE DRILLS 31
OTHER EVACUATION DRILLS 31
5-YEAR DELAY FOR SPRINKLER SYSTEM: CLASS C 26
COMPREHENSIVE INDIVIDUALIZED SERVICE PLAN 25
LICENSEE COMPLIES WITH LAWS 23
SUPERVISION 20
RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION 17
PRE-ADMISSION AND ONGOING ASSESSMENTS 17
RIGHTS OF RESIDENTS: PROMPT AND ADEQUATETREATMENT
15
ADMINISTRATOR SHALL SUPERVISE DAILYOPERATION
15
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Top Ten Cites with Forfeiture
CBRF 2014
15,000
17,075
17,500
18,890
28,140
38,800
42,500
44,590
56,176
73,100
NOT PERMIT A CONDITION OF…
ADMINISTRATOR SHALL SUPERVISE DAILY…
COMPREHENSIVE INDIVIDUALIZED…
PRE-ADMISSION AND ONGOING…
RIGHTS OF RESIDENTS: TO RECEIVE…
QUALIFIED STAFF IN CHARGE, ON DUTY…
HEALTH MONITORING
RIGHTS OF RESIDENTS: PROMPT AND…
SUPERVISION
SERVICE PLANS UP OR ON CHANGES
$0 $20,000 $40,000 $60,000 $80,000
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
AFH Top Ten Citations CY 14
0
20
40
60
80
100
120
140
160
NUMBER OF CITATIONS
ENTITY SANCTION (4 YEAR CBC) 148
EXITING FROM THE FIRST FLOOR 19
REVIEW OF ISP 27
SMOKE DETECTORS-TESTING AND MAINTENANCE 15
TRAINING-15 HOURS WITHIN 6 MONTHS 11
MEDICATION- WRITTEN ORDER 11
MEDICATION- WRITTEN ORDER 11
INDIVIDUAL SERVICE PLAN & ASSESSMENT 10
SERVICE AGREEMENT EXCEPT RESPITE 10
SAFE PHYSICAL ENVIRONMENT 9
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
RCAC Top Ten Citations CY 14
0
1
2
3
4
5
6
7
8
9
10
NUMBER OF CITATIONS
12.05(1)a ENTITY SANCTION (4 YEAR CBC) 10
89.34(16) TENANT RIGHTS 3
89.23(1) SERVICES 2
89.35(3) GRIEVANCES 2
89.29.23(2)(a)2.c SERVICES 2
13.05(2) CLIENT PROTECTION 2
89.26(4) ANNUAL REVIEW 2
89.23(2)(b)1 SERVICES 1
89.29(1)b ADMISSION/RENTENTION 1
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
ADC Top Ten Citations CY 14
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
NUMBER OF CITATIONS
ENTITY SANCTION (4 YEAR CBC) 2
PLAN-QUARTERLY DOCUMENTING 2
TRAINING-CONTINUING EDUCATION 2
PLAN-REVIEWED & UPDATED EVERY 6 MONTHS 1
PLAN-FOSTER INTERACTION 1
HEALTH STATEMENT 1
PLAN-COMPREHENSIVE WRITTEN ASSESSMENT 1
PLAN-IDENTIFIED NEEDS WITH 30 DAYS 1
PERSONNEL-HEALTH EXAMINATION 1
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Enforcement
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living
• Surveyors
oRegistered nurses
oHealth/human service professionals
• Regional Office Directors
• Program Support
• Quality Assurance Staff
o Enforcement Specialist (centralized)
o Lead Internal QA program.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living
Structure • Enforcement Specialist Qualifications
o Experienced investigator
oClinical expertise (health or human service)
oRegulatory experience
o Program evaluation
• Lead Role / Quality Assurance
• Appeals / Hearings
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Enforcement Philosophy
1. Use sanctions that can improve systemic concerns so communities can correct and sustain compliance
2. Progressive sanctions
3. Aggressive action against the communities with persistent or serious noncompliance
4. Root Cause Analysis
5. Collaborate with other agencies, including Advocates, OCQ, DSPS, OIG, Counties, MCOs and Department of Justice and Attorney General
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Enforcement “Rule of
Thumb” Apply constructive enforcement strategies that require providers to address the "root causes" of violations and use a "progressive" enforcement approach by reserving higher forfeitures and stronger sanctions for serious and repeat compliance problems.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurvCertPromPractProj/downloads/CreativeEnforcement_IssueBrief.pdf
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
0
100
200
300
400
500
600
2003 2004 2005 2006 2007 2008 2009 2009minus
4 yrentity
2010 2011 2012 2013 2014 20144 yr
entity
2014sm.
ClassC
Enforcements 471 442 409 475 546 474 486 444 522 475 421 439 410 240 46
AL Surveys with Enforcement
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
0
20
40
60
80
100
120
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
44
57 49
105
89 82 78
82
61
79
Assisted Living No New Admission Orders
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
0
2
4
6
8
10
12
14
16
2007 2008 2009 2010 2011 2012 2013 2014CBRF 8 15 14 10 2 9 8 3
AFH 8 8 6 6 5 12 5 9
RCAC 0 1
ADC 0
Impending Revocations
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Total 1 8 19 3 4 15 10 15 13 9 5 16 8 11
ADC 1 1 1 1
RCAC 1 1
AFH 1 3 7 1 1 5 4 6 6 7 2 9 1 10
CBRF 5 11 2 2 10 5 8 6 2 3 7 6 1
05
10152025303540
Revocations by Community
Type – Historical
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Forfeiture Assessments
$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
$700,000
$800,000
$900,000
$1,000,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
$439,406
$547,300
$433,055
$614,952
$422,530
$608,989
$889,925
$816,600
$979,313 $1,036,165.00
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Sanctions Imposed (1,493)
CY 2014
871
560
62
CBRF AFH RCAC
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Type of Sanctions per survey
CY 2014
316
387 323
4
14
79
285
59 Comply POC
Comply Req.
Forfeiture
Provide Training
Revoke/Deny
No Admission
Other
Accruing Foreiture
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
0
10
20
30
40
50
60
70
80
90
100
25% 50% 75% 100%
3.9 7.3 10.9 14.5
Percent of Facilities Making Up
a Percentage of Enforcements
CY 2014
% of Facilities % of Enforcement
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Surveys with
Citations/Appeals
95%
5%
Surveys with Citations
Appeals
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living WCCEAL
Regulatory Data
CY 2014
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
CBRFs AFHs RCACs
2013 187 48 100
2014 227 32 106
0
50
100
150
200
250
WCCEAL Regulated Communities
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Communities
Surveys Conducted
Total SurveysSurveys With
CitationsTotal Citations
IssuedSurveys With No
Citations
2013 189 75 211 114
2014 244 73 193 144
0
50
100
150
200
250
300
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Members Complaints
2013 2014
Total Facilities 336 365
Total Complaints 115 157
Facilities With Complaints 74 98
0
50
100
150
200
250
300
350
400
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Regulated Communities
Qualifying for Abbreviated Surveys
2013 2014
Total Number of Facilities 336 365
Qualifying Facilities 221 215
RCAC 82 78
CBRF 108 118
AFH 31 19
050
100150200250300350400
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Regulated Communities
Abbreviated Survey Results
2013 2014
Total Abbreviated Surveys 40 32
Surveys with no citations 28 23
Surveys with citations only 8 4
Enforcement Action 4 5
05
1015202530354045
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Percent of Facilities Making
up a Percent of Complaints
0
5
10
15
20
25
30
2013 2014
22
26.8
15.6
19.4
WCCEAL
Non-WCCEAL
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Average Citation Per Survey
0
0.5
1
1.5
2
2.5
3
3.5
2013 2014
2.8
2.6
3.3
2.3
WCCEAL
Non-WCCEAL
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living
Strategies
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2014 BAL Initiatives (Past)
• RESOLVE Forums
• LEAN Application Project
• Assisted Living Summit
• Transitions in Care (Assisted Living
Transitions Coalition)
• Intellectual Disability training
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2014 BAL Initiatives (Past)
• Individual Service Plan/Assessment
training
• Continued Implementation of WCCEAL
• Resident Centered Care Workshops
• Bureau of Assisted Living Publications
• Strategies to Enhance Resident Care.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Provider Search Application
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Resident Centered Care:
Back to the Basics
Date or subtitle WI State Bureau of Assisted Living and Wipfli LLP
© Wipfli LLP
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
ISP Train the Trainer
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Strategies to Enhance Resident Care
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Transitions in Care Coalition
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Intellectual Disability Train the
Trainer
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WI Coalition for Collaborative
Excellence in Assisted Living
• Provider Association Sponsored
• Department Approved
• Comprehensive QA & QI
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Internal Quality Assurance
• Essential to maintain
quality!
• Structure, process and
outcome measures used to
evaluate quality
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
What does DHS expect if there
are issues identified with individual AL communities …
• The AL community will develop mechanisms to
improve quality;
• CHSRA will assist the associations to identify issues
from the reports and propose strategies to improve;
• The AL community’s associations will provide
assistance and support to improve; and
• The AL community’s association will hold the
community responsible for implementing their QI/QA
program.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2015 BAL Initiatives (Future)
• Completion of LEAN Application Project
• E-Licensure/E-payment
• RESOLVE Forums
• Individual Service Plan Train-the-Trainer
• Explore Licensing Application Workshops
• Reducing Falls project
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
2015 BAL Initiatives (Future)
• Assisted Living Self-reports Project
• Increase electronic delivery of Statement of Deficiencies
• Assisted Living Forum
• Increase awareness of evidence-based practices
• Evaluate the Assisted Living Survey Process
• Develop a pilot of the INTERACT tools
• HCBS Implementation
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
*Diagram Source: CGAP
… continued
INTERACT
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Initiatives:
Individual AL Community
• Conduct thorough onsite surveys and provide results
in a timely manner.
• Provide technical assistance as needed.
• Encourage development of internal QI program.
• Share evidence-based practices.
• Promote individual meetings with AL Community
to engage in dialogue about compliance issues and
AL communities plans to achieve substantial
compliance.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Initiatives:
Consumer Access to Regulatory
Information
• Develop BAL manual that
includes all relevant
regulatory information in
provider-specific documents.
• Ensure all relevant
information is included on
the provider search
application
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
BAL Initiatives:
Assisted Living Stakeholders
• Engage assisted living stakeholders
to support quality improvement
activities in AL communities.
• Identify, plan and implement in-
person or web based trainings to
address compliance issues.
• Encourage the recognition and
implementation of evidence-based
practices.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Evidence-Based Practices
• Encourage utilization of current evidence-
based practices.
• Develop facility policy and procedures,
based off of current evidence-based
practices.
• Staff training on policies and procedures.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bridging the two models of care
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Home Community Based
Services Waiver • Public funding agencies should use the work of the regulatory
agency as part of their quality assurance program …..
CMS
WI Medicaid Program
County/Managed Care
Organizations
Bureau of Assisted
Living
Facility
Shared Goal:
Improve Personal
Health and the Health
Care Delivery system
Quality
Assurance
Care
Management
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
A licensee failed to provide proper care and treatment for a
resident with intellectual disabilities. The licensee would not allow
the resident to dress him/herself as “it was quicker to just do it.”
The surveyor observed the licensee “abruptly” thrust a tooth brush
into the resident’s mouth without forewarning or explanation. The
resident’s head “jerked back” and the resident repeatedly
verbalized wanting the licensee to “stop.” The licensee responded
by asking if the resident wanted his/her teeth “pulled out instead.”
The licensee acknowledged pressing a “cold gallon of milk” on the
resident’s stomach, putting “ice” down the resident’s shirt, and
pulling the back of the resident’s shirt over the top of his/her head
to purportedly “redirect” behaviors and “improve mood.” The
licensee also stated that the residents “are really just kids in adult
bodies and they need to be treated like children.”
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
A facility did not provide needed care and services for a resident
with complex medical needs including multiple pressure sores and
weight loss. Pressure relieving devices were not provided as
prescribed by the physician. Weight loss was not monitored
because the facility “did not have the proper scale to weigh a
resident who was unable to stand and bear weight.” The facility
continued to send the resident to a day program despite his/her
markedly frail condition. Hospital records indicated the resident
was “severely malnourished” with 14 pressure sores, including one
wound that was described as a “Stage 4 pressure ulcer with bone
exposed, with no viable tissue noted…and odor… In the patient’s
current state, there is little hope that s/he will heal any wounds.”
The resident was discharged with hospice services.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
A facility maintenance worker was observed “hugging and
kissing a resident.” During a second incident, witnesses
reported the worker was in the bathroom with the resident
and the door was closed. A caregiver knocked on the door
and waited for “a minute to a minute and a half.” When the
door opened, the worker came out quickly and went down
the hall. Upon entering the bathroom, the caregiver observed
the resident with “pants unbuttoned, pants and
undergarment rolled together and a portion of the resident’s
upper buttocks showing.” The employee was permitted to
continue working, without monitoring, for 26 more days.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
A resident had a witnessed fall resulting in bruising
and worsening pain. The facility did not seek
prompt medical care until 2 days later when a
family member insisted on medical care. The
resident was admitted to the hospital with 4
fractured ribs and returned to the facility with
Hospice care. The resident died the same month.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
Over a 6-month period, the facility failed to
protect residents from abuse. A resident with
known behavioral problems, including
aggressive outbursts, yelled at, bullied,
threatened, kicked, threw objects at, and hit
other residents.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
Inexperienced caregivers had been assigned to
transfer a resident with MS (Multiple Sclerosis) from
the bed to a wheelchair with a Hoyer lift. The
resident was not properly positioned and the
resident’s leg became entangled between the bed and
wheelchair. Once in the wheelchair, the caregiver
pulled on the Hoyer sling for repositioning and a
“loud pop” was heard. The resident had sudden,
severe leg pain and was admitted to the hospital with
a fractured femur.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
A resident, hospitalized 7 times in a 2-month period, did
not receive adequate treatment for multiple falls with
injuries, including head lacerations requiring staples, a neck
fracture, and significant urinary tract infections requiring
hospitalizations due to sepsis (a severe infection that has
spread via the blood stream). Caregivers did not
consistently apply a neck brace or adjust the brace to
prevent open areas from developing, did not ensure that
chair/bed alarms were applied and functioning, and did
not provide needed incontinence care to prevent skin
breakdown and urinary tract infections
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
Caregivers neglected to intervene promptly when a resident
with dementia fell. Instead, caregivers informed oncoming
staff during a verbal shift report that the resident had fallen
and was lying on a bedside mat. The resident was found non-
responsive, with a cut to the head. When rescue personnel
arrived, it appeared that the resident had been left on the floor
mat, “unchanged” and “smelling of urine” for an unknown
length of time. The resident sustained a laceration on the right
forearm that extended about ½ of the forearm and a skin
abrasion above the left eye.
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Stories
Over a 3-month period, staff did not administer
pain patches, anxiety medications, and other
prescribed medications for a resident with
diagnoses of chronic pain and anxiety
Bureau of Assisted Living Vision
Reasonable and consistent
Promotes public health and safety
Fosters quality of life
Promotes provider responsibility
Promotes regulatory agency responsibility
Fosters collaboration
Supports consumer awareness, responsibility
and satisfaction
Promotes consumer independence and choice
Protects vulnerable adults
Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Alfred C. Johnson, Director Bureau of Assisted Living
Phone: 608-266-8598 Email: alfred.johnson@wi.gov
Wisconsin Bureau of Assisted Living
DQA - Working to Protect - Promote - Provide Quality in Wisconsin's Health Care Facilities