“State of Assisted Living” · Wisconsin Department of Health Services. Assisted Living. 0....

Wisconsin Department of Health Services

“State of Assisted Living”

Calendar Year 2013


Agenda

1. Organizational Chart/Regional Office Locations

2. Trends and Statistics

o AL Capacity

o Affiliation/Ownership Trends

o Enforcement Trends

o Citations/Sanctions

o Complaints

o Self-Reports

o Abbreviated Surveys

3. WCCEAL

4. Looking Ahead

5. Regulatory Stories

6. Wrap-up


BAL Org. Chart

BAL Alfred C. Johnson

Dir.

NERO Kathy Lyons, ALRD

8 surveyors 2 support staff

WRO Bill Gardner, ALRD


SRO Mark Andrews, ALRD


SERO Carolyn Happel, ALRD

8 surveyors

2 support staff

2 QAPS 1 Research Tech. 1 Office Operations

Associate (50%)


Trends & Statistics


Nursing Home & FDDs

0

500

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20132003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

FDDS 37 35 32 22 19 16 14 14 13 13 12NHs 407 404 404 403 402 399 399 399 400 397 399

Trend in Number of Facilities


Nursing Home & FDD

01000020000300004000050000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013FDDS 2391 2115 1734 1354 1190 1102 989 939 908 768 720NHs 40661 39959 39276 38700 38106 37494 36557 36022 35661 34992 34639

Trend in Capacity for Residents


Wisconsin Assisted Living 35th Consecutive Year of

Growth!!


Assisted Living

0

500

1000

1500

2000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013RCAC 152 171 188 203 218 245 271 278 295 303 308AFH 765 834 965 1049 1130 1185 1273 1392 1467 1544 1621CBRF 1352 1367 1372 1382 1403 1429 1458 1470 1476 1501 1514

Num

ber o

f Fac

ilitie

s



Assisted Living

05000

1000015000200002500030000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013AFH 2964 3217 3727 4054 4358 4585 4916 5430 5730 5987 6285RCAC 6055 6614 8003 8980 9562 10579 11988 12330 13176 13580 14069CBRF 21392 21739 21996 22408 22822 23490 24366 24765 25201 25985 26750

Capa

city

Trend in Assisted Living Capacity


RCACs

0

100

200

300

400

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Certified 86 94 104 115 125 147 174 184 196 204 210Registered 67 77 84 88 93 100 97 94 99 99 98Total 153 171 188 203 218 247 271 278 295 303 308

Num

ber o

f Fac

ilitie

s

Certified vs. Registered


CBRF

0 5000 10000 15000 20000 25000

Class AA

Class ANA

Class AS

Class CA

Class CNA

Class CS

Class AA Class ANA Class AS Class CA Class CNA Class CSCapacity 2993 385 801 233 21223 1155Number of facilities 288 16 75 34 1011 93

Capacity Report


AL vs. LTC

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013AL 2269 2372 2525 2634 2751 2859 3001 3238 3348 3348 3577LTC 444 439 436 425 421 415 413 413 413 410 411

0

500

1000

1500

2000

2500

3000

3500

4000

Num

ber o

f Fac

ilitie

s



AL vs. LTC

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013LTC 43052 42074 41010 40054 39296 38596 37546 36961 36569 35760 35359AL 30411 31570 33726 35442 36742 38654 41270 42525 44107 45552 51158

0

10000

20000

30000

40000

50000

60000

Capa

city

Trend in Capacity for Residents


Adult Day Care Facilities

0

50

100

150

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013ADC 101 105 106 97 102 114 115 121 128 134 134

Num

ber o

f Fac

ilitie

s



Adult Day Care Facilities

0500

10001500200025003000350040004500

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013ADC 2526 2578 2582 2617 2770 3101 3097 3407 3471 3874 4054

Trend in the Capacity for Participants


Assisted Living Facilities by Affiliation

0200400600800

10001200140016001800

ADC AFH CBRF RCACIndependent 73 641 322 83Affiliated 60 1106 1267 256

Num

ber o

f Fac

ilitie

s


Percent of Facility Types Affiliated 2013

ADC AFH CBRF RCACAffiliated 45% 63% 80% 76%Independent 55% 37% 20% 24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Perc

ent o

f All

AL F

acili

ties


Ownership by Count – All CY 2013

654

47 50

4

1201

1371

85

363 34

Non-profit Corp.ChurchGov'tTribalProfit Corp.Profit LLCProfit PartnershipProfit ProprietaryOther/NA


Ownership by Percentage 1%

32%

17% 1% 0%

0%

36%

2%

10% 0% 1% 2013

Church

Corporation-Business

Corporation- Non-profit

Government- County

Government-State

Government- Other

Limited Liability Company

Partnership

Proprietorship

Tribal

Other


Ownership – ADC CY 2013

48

7

9 0

30

12

3

21

3



Ownership – AFH CY 2013

220 7 10

0

572

546

67

300 25



Ownership – CBRF CY 2013

19%

1% 1%

0%

34%

41%

1% 3% 0%



Ownership – RCAC CY 2013

89

13

9 0

58

163

3 2 2 Non-profit Corp.

Church

Gov't

Tribal

Profit Corp.

Profit LLC

Profit Partnership

Profit Proprietary

Other/NA


New AL vs. Closed AL

0

50

100

150

200

250

300

350

400

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013new 247 322 352 321 282 296 350 315 363 328closed 223 243 323 293 279 245 357 279 337 315

Num

ber


Why Facilities Closed 2013

116

85

20

17

14

21

10

32

VoluntaryCHOWWithdrew App.Location ChangeConversionNon-renewalRevoke/DenyInactive


Post Survey Questionnaire

2013 – 68 respondents

Satisfaction with survey tasks 97.40 %

On Site - 4.64

• Knowledgeable - 4.63

• Professional - 4.71

• Respectful - 4.73

SOD – 4.22

1 = strongly disagree

5 = strongly agree


An effective enforcement process can help move an industry to improved quality…

http://www.epa.gov/region5/enforcement/images/encmt.jpg

http://images.google.com/imgres?imgurl=http://www.ideachampions.com/creative-thinking.jpg&imgrefurl=http://www.ideachampions.com/creative_thinking.shtml&h=346&w=259&sz=28&hl=en&start=3&tbnid=JzQig47O7IRk_M:&tbnh=120&tbnw=90&prev=/images?q=creative&svnum=10&hl=en&lr=


Enforcement Philosophy Use enforcement to help move the industry to quality

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. Collaborate with other agencies, including

Advocates, OCQ, DSPS, OIG, Counties, MCOs and Department of Justice and Attorney General


AL Citations Issued

CY2004

CY2005

CY2006

CY2007

CY2008

CY2009

CY2010

CY2011

CY2012

CY2013

Total Cites 2421 2625 2569 2759 2369 2417 2623 2471 2420 2091Ave per Survey (when cites are

given) 3.3 3.3 3.7 3.3 3.0 2.9 3.4 3.6 3.3 3.2

0

0.5

1

1.5

2

2.5

3

3.5

4

0

500

1000

1500

2000

2500

3000


Top Ten CBRF Citations

0 10 20 30 40 50 60 70

PRN PSYCHOTROPIC MEDICATION

COMPREHENSIVE INDIVIDUALIZED SERVICE…

CONTINUING EDUCATION

ADMINISTRATOR SHALL SUPERVISE DAILY…

HEALTH MONITORING

OTHER EVACUATION DRILLS

SUPERVISION

RIGHTS OF RESIDENTS: TO RECEIVE…

LICENSEE ENSURES FACILITY COMPLIES…

SERVICE PLANS UPDATED ANNUALLY OR…

33

34

35

35

38

40

40

40

51

70


Top Ten Cites with Forfeiture CBRF 2013

BEHAVIOR MANAGEMENT

ADMINISTRATOR SHALL SUPERVISE DAILY…

QUALIFIED STAFF IN CHARGE, ON DUTY AND…

SERVICES PLANS UPDATED ANNUALLY OR…

LICENSEE ENSURES FACILITIEY COMPLIES…

LEISURE TIME ACTIVITES

RIGHTS OF RESIDENTS: TO RECEIVE…

RIGHTS OF RESIDENTS: PROMPT AND…

HEALTH MONITORING

SUPERVISION

$29,700

$29,920

$30,040

$35,200

$36,060

$36,900

$43,295

$47,150

$53,300

$63,650


Top Ten AFH Citations

0 5 10 15 20 25 30

FIRE SAFETY EVACUATION PLAN REVIEW

SMOKE DETECTORS-TESTING AND…

HEALTH SCREENING FOR STAFF

REVIEW OF ISP

DIFFICULTY WALKING

TRAINING-15 HOURS WITHIN 6 MONTHS

CONDITION WHICH REPRESENTS RISK OR…

FIRE EVACUATION ANNUAL EVALUATION

HOME ENVIRONMENT

SAFE PHYSICAL ENVIRONMENT

14

14

14

16

17

17

17

19

21

26


Top Ten RCAC Citations

0 1 2 3 4 5

SERVICES-NURSE QUALIFICATIONS

SERVICES-PROVIDER QUALIFICATIONS

SERVICES-APPROPRIATE TO NEEDS, ABILITY…

SERVICES-NURSING SERVICES

ADMISSION & RETENTION OF TENANTS

RISK AGREEMENT-UPDATING

RISK AGREEMENT-REQUIREMENT

ANNUAL REVIEW

SERVICES-STAFF TRAINING IN SAFETY…

ENTITY ALLEGATION REPORTING

2

2

2

2

3

3

4

5

5

5


Top Ten ADC Citations

0 1 2 3 4 5

MEDICAID WAIVER FUNDS

FIRE PROTECTION

SANITATION-PREMISES CLEAN

PLAN-REVIEWED & UPDATED EVERY 6…

HEALTH STATEMENT

PRIVACY AND CONFIDENTIALITY

MEDICATION-WRITTEN ORDER

FIRE ALARM & SMOKE DETECTORS

PERSONNEL-HEALTH EXAMINATION

MEDICATION-LOCKED SAFE PLACE

2

2

2

2

2

2

4

5

5

5


Survey Results – Statewide

0%

10%

20%

30%

40%

50%

60%

70%

No Cites SOD Only Surveys 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%


Survey Results 2013

65%

14%

21%


2013 Survey Results

63% 12%

25% 2010

65% 14%

21% 2013 No SODSODSOD W/ Enfor.

65% 14%

21% 2012

63% 15%

22% 2011


0

100

200

300

400

500

600

2003 2004 2005 2006 2007 2008 2009 2009minus

4 yrentity

2010 2011 2012 2013

Enforcements 471 442 409 475 546 474 486 444 522 475 421 439

AL Surveys with Enforcement


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

$439,406

$547,300

$433,055

$614,952

$422,530

$608,989

$889,925 $816,600

$979,313


35% Forfeiture Reduction

2005 2006 2007 2008 2009 2010 2011 2012 2013# Pd Reduction 202 213 268 226 277 278 265 260 276Other Pmt 92 83 123 91 63 84 98 49 88% choosing 35% 68% 72% 69% 71% 77% 77% 73% 84% 76%

0

50

100

150

200

250

300


Sanctions Imposed (828) CY 2013

634

156 35 3

CBRF AFH RCAC ADC


Type of Sanctions per Survey CY 2013

252

145

306

3

6 61 26 13

Comply POCComply Req.ForfeitureProvide TrainingRevoke/DenyNo AdmissionOtherAccruing Foreiture


0

20

40

60

80

100

120

2005 2006 2007 2008 2009 2010 2011 2012 2013NNAO 44 57 49 105 89 82 78 82 61

No New Admission Orders


0

2

4

6

8

10

12

14

16

2007 2008 2009 2010 2011 2012 2013CBRF 8 15 14 10 2 9 8AFH 8 8 6 6 5 12 5RCAC 0 1ADC 0

Impending Revocations


Impending Revocations CY 2013


0

1

2

3

4

5

6

7

8

2005 2006 2007 2008 2009 2010 2011 2012 2013Total 8 7 1 3 5 1 1 5 2

Cease & Desist Orders Unlicensed Entity


Revocations

02468

101214161820

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013CBRF 11 2 2 10 5 8 2 3 7 6AFH 7 1 1 5 4 6 6 7 2 9 1RCAC 1 0 0 0 0 0 6ADC 1 0 1 1 1 1Total 19 3 4 15 10 15 13 9 5 16 8


0102030405060708090

100

25% 50% 75% 100%

2.3 4.6 6.9 9.3

Percent of Facilities Making Up a Percentage of Enforcements

CY 2013

% of Facilities % of Enforcement


Complaints Received

0100200300400500600700800900

1000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013# complaints 792 667 677 718 681 774 836 789 801 916 900


Complaints Received CY 2013

9

191

617

82

ADCAFHCBRFRCAC


Complaints vs. Growth

0

500

1000

1500

2000

2500

3000

3500

4000

2003- 2013

# complaints # AL Facilities


Percent of Facilities Making up a Percent of Complaints

0102030405060708090

100

25% 50% 75% 100%

3.9 7.9

11.8 15.8

% of Facilities % of Complaints


Source of Complaint CY 2013

26%

14%

25%

12%

13%

2% 5% 2% 1%

AnonymousPublic OfficialRelative/GuardianCurrent EmployeeFormer EmployeeMedicalCitizenResidentAdvocate


Ranking – Subject Areas of Complaint Investigations

2007 2008 2009 2010 2011 2012 2013 Administration 2 2 1 1 2 2 2 Medications 3 1 3 3 3 3 3 Resident Rights 1 3 2 2 1 1 1 Program Services 4 4 4 4 5 5 4 Nutrition & Food 8 6 6 8 4 4 7 Staff Adequacy 7 5 8 6 7 7 8 Supervision 6 8 5 5 8 8 6 Staff Training 11 9 7 7 6 6 5


Ranking – Subject Areas of Complaint Investigations (continued)

2007 2008 2009 2010 2011 2012 2013 Abuse 5 7 9 11 12 12 12 Homelike environment 9 10 10 10 10 10 9 Physical Plant & Hazards 12 13 11 12 11 11 11 Res. Behavior/ Facility practice 10 11 13 13 13 13 10

Quality of Life 13 12 12 9 9 9 13 Admission/

Discharge 14 14 14 14 14 14 14 License capacity or class 16 15 15 15 15 15 15 Restraints 15 16 16 16 16 16 16


Source % rec. & Inv. % substantiated Anonymous 26 25 Public Official 14 48 Relative/Guardian 25 32 Current Employee 12 27 Former Employee 13 30 Advocate 01 63 Citizen 05 20 Medical 02 44 Resident 02 19 100% 31%

Source of Complaint vs. Substantiation

CY 2013


Self Reports Received

0

500

1000

1500

2000

2500

3000

3500

4000

2005 2006 2007 2008 2009 2010 2011 2012 2013

1166 1452

1856 1872

2751

3446 3271

3534 3343


Self Reports Received CY 2013 (3,343)

225 117

2980

Open Investigation

Review Next Visit

File


Number of Self Reports by Subject Area CY 2013

1749

182

312

269

482

187 72 72 13 25 7 3 Falls

Res. BehaviorPoliceElopementHospital (not fall)OtherMisappropriationAbuseNeglectFireComm. DiseaseDisaster/Evacuation


332

23

Self Reports Investigated – CY 2013 (355)

No SOD

SOD


Assisted Living Regulatory Activity CY 2013

• Standard Surveys 486

• Initial Surveys 323

• Abbreviated 408

• Other (Enf. VV & Complaint) 879


Abbreviated Surveys CY 2013

• No Deficiency Survey - 64%

• Statement of Deficiency - 36%


Facilities Qualifying for Abbreviated Surveys – CY 2013

• Adult Day Care 62.7%

• Adult Family Homes 53.3%

• Community Based Residential Facility 50.7%

• Residential Care Apartment Complex 53.9%

• Statewide 53.5%


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 2013Abbrev. 37.20 37.90 38.20 40.50 39.30 42.40 45.70 46.70 46.80 50.80 53.50


Wisconsin Coalition for Collaborative Excellence in Assisted

Living (WCCEAL)


Internal Quality Assurance

• Essential to maintain quality!

• Structure, process and outcome measures used to evaluate quality


http://www.alfa.org/alfa/default.asp

http://www.leadingagewi.org/


WCCEAL Regulatory Data CY 13


CBRFs AFHs RCACs WCCEAL Assisted Living

Communites 187 48 100

020406080

100120140160180200

WCCEAL Regulated Communities CY 13


WCCEAL Regulated Communities Surveys Conducted

Total Surveys Surveys WithCitations

Total CitationsIssued

Surveys With NoCitations

CY 13 189 75 211 114

0

50

100

150

200

250

CY 13


WCCEAL Members Complaints CY 13

Total Facilities 336total Complaints 115Facilities With Complaints 74

050

100150200250300350400


WCCEAL Regulated Communities Qualifying for Abbreviated Surveys

CY 13

Total Number of Facilities 336Qualifying Facilities 221RCAC 82CBRF 108AFH 31

050

100150200250300350400


WCCEAL Regulated Communities Abbreviated Survey Results

CY 13

Total Abbreviated Surveys 40Surveys with no citations 28Surveys with citations only 8Enforcement Action 4

05

1015202530354045


Percent Making Up Percent of Complaints CY 13

0

5

10

15

20

25 22

15.6

WCCEALNon-WCCEAL


Average Citation Per Survey CY 13

2.5

2.6

2.7

2.8

2.9

3

3.1

3.2

3.3

2.8

3.3

WCCEALNon-WCCEAL


Looking Ahead


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


Bureau of Assisted Living Regulatory Goal

Positive Resident Outcome


Our Focus

• Bureau of Assisted

Living

Regulator

• Assisted Living Community

Service Provider

• Resident/Consumer

Positive Outcome


Collaboration • “Rally resources” –

engage all relevant stakeholders to support quality improvements


Regulatory Stories


Thank You

Alfred C. Johnson, Director Bureau of Assisted Living

Phone: 608-266-8598 Email: [email protected]

Wisconsin Division of Quality Assurance

The Division of Quality Assurance (DQA) is responsible for assuring the safety, welfare and health of persons using health and community care

provider services in Wisconsin.

DQA - Working to Protect - Promote - Provide Quality in Wisconsin's Health Care Facilities

http://www.dhs.wisconsin.gov/

“State of Assisted Living” · Wisconsin Department of Health Services. Assisted Living. 0....

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