health and wellness for all arizonans maintaining compliance in residential facilities

Health and Wellness for all Arizonans

Maintaining Compliance in Residential Facilities


Arizona Department of Health ServicesCara Christ M.D., Director

Division of Public Health Licensing

Bureau of Residential Facilities LicensingDiane Eckles, Bureau Chief


Office Locations and Phone Numbers• Phoenix: 150 N. 18th Ave., Suite 420 • 602-364-2639 FAX: 602-324-5872

• Tucson: 400 W. Congress St., Suite 116 • 520-628-6965 FAX: 520-628-6991

Website: http://azdhs.gov/licensing/residential-facilities/index.php

Email: [email protected]

http://azdhs.gov/licensing/residential-facilities/index.php


mailto:[email protected]


Bureau of Residential Facilities Licensing (BRFL)

• Licenses, regulates, and provides training to Residential Healthcare Facilities; including Assisted Living Centers, Assisted Living Homes, Adult Foster Care Homes, Behavioral Health Residential Facilities, Adult Day Health Care Facilities, Behavioral Health Respite Homes, and Adult Behavioral Health Therapeutic Homes based on Arizona’s Rules and Statutes

• Our goal is COMPLIANCE – we want to help you to be in compliance with the applicable Rules and Statutes for your facility

• It is your responsibility to ensure you are aware of the rules as they apply to your facility


Applicable Rules and Statutes• Licensing of Residential Facilities is governed by the Arizona Revised

Statutes (“A.R.S.”), primarily Title 36: Public Health and Safety, Chapter 4: Health Care Institutions

• Reference to a statute generally uses this format: A.R.S. § 36-401.A.1. or A.R.S. § 36-401(A)(1)

• Reference to a rule is generally in this format:– Title 9, Chapter 10, Article 8 (specific subclass), Rule Number 803.A.3.a– Example of an Assisted Living Rule

• R9-10-803.A.3.a

Statutes are law that authorize the Department to adopt Rules which are specific to each facility type

http://www.azleg.gov/ArizonaRevisedStatutes.asp?Title=36

http://www.azleg.gov/ArizonaRevisedStatutes.asp?Title=36

http://www.azleg.gov/FormatDocument.asp?inDoc=/ars/36/00401.htm&Title=36&DocType=ARS




Rules Governing Residential Facilities

Article 1: GeneralArticle 7: Behavioral Health Residential FacilitiesArticle 8: Assisted Living FacilitiesArticle 11: Adult Day Health Care FacilitiesArticle 16: Behavioral Health Respite HomesArticle 18: Adult Behavioral Health Therapeutic

Homes

You can find the most up-to-date copy of the rules at our website: http://www.azdhs.gov/licensing/residential-facilities/index.php#providers-home

http://www.azdhs.gov/licensing/residential-facilities/index.php#providers-home

http://www.azdhs.gov/licensing/residential-facilities/index.php#providers-home


The Survey Process

• Compliance–are you ready for inspection?• Most inspections are unannounced• Length of inspection varies depending on: – Size of facility– Completeness and organization of records– Compliance with the rules

• Surveys follow current rules, statutes, and the facility P&P’s


The Survey Process

• Surveys will be conducted based on the outcomes and the facility’s Policies & Procedures (P&Ps)

• The rules require facilities to establish, document, and implement Policies and Procedures (P&Ps) to protect the health and safety of a resident

• Know your scope of services


Types of Surveys

There are five main kinds of surveys that surveyors will conduct:• Initials• Change of Ownership (CHOWs)• Compliance• Amends• Complaints


Licensure Period

• Your licensure period runs for 12 months. – Not always going to be January 1-December 31– A surveyor can show up at ANY point within your

licensing period for the compliance survey– Compliance survey may not be the same month

year after year


CHOWs• CHOW = Change of Ownership• If you are purchasing or leasing a facility that is already

licensed as a Residential Facility, this is referred to as a “CHOW”

• A.R.S. 36-422.D: the current licensee must notify the Department in writing at least 30 days prior to the planned change of ownership and ensure services are not interrupted

• The new owner may not begin operating the facility until the Department issues a license.

• If the facility receives an inspection, it is treated similar to an Initial




Compliance• Inspection is conducted once per licensing period• The Surveyor will check for health and safety issues and

outcomes • The Surveyor will also conduct a tour of the facility, review the

facility’s P&Ps, resident records, employee records, and facility records

• The Surveyor will also conduct interviews, as appropriate, during the inspection

• You are encouraged to accompany the Surveyor during the inspection process and to ask questions

• Please take notes during the survey; the Surveyor cannot give you a copy of his/her notes

• If you’re deficiency free – kudos


Amend• Anything that changes the existing license– Bed Increase or Decrease– Adding a service such as:

• Personal Care for BH• Behavioral Health Services for AL• Outdoor Behavioral Health Program for BH• Changing the level of care

• Submit a written request to make a change• Surveyor will ensure compliance before the

facility is allowed to make a change


Complaints• Sometimes, complaints are received on your

facilities• Don’t take it personally• All complaints are confidential, surveyors do

not release the complainant information• Surveyors will look to see WHAT happened

and deficiencies will be cited if there was a failure on the facility’s behalf


All Surveys

• The surveyor will always present a “Notice of Inspection Rights”, often referred to as an “Entrance Letter”

• Anyone in the facility can sign it, Surveyors don’t have to wait for the manager or administrator to sign

• Read it carefully and ask the surveyor if you have any questions or concerns

• You will be asked to sign it, but if you don’t, the survey will continue to be conducted


Statement of Deficiencies (“SOD”)• After the inspection is compete, the Surveyor will conduct an exit

interview with the manager/administrator or designee to inform them of findings found– Department will not give a list of deficiencies

• Findings may or may not mean deficiencies– TA Discussion

• Rosters will not be sent – need systemic fix & HIPAA• If you have no deficiencies:

– A “No-Deficiency” Statement of Deficiencies is written• If you have deficiencies:

– Surveyor & Team Lead review data to determine citations– A Statement of Deficiencies (SOD) is mailed – An acceptable Plan of Correction is required(POC)


Plan of Correction (“POC”)

• Required from the facility after a facility received a SOD with deficiencies

• Please read the cover letter that comes with the SOD carefully. It gives you information and deadlines that apply to your situation

• You will need to write a POC for each citation on the space provided on your SOD or attach the POC on a separate paper



The POC must outline the specific steps taken to correct each deficiency noted, and must include the following:1. How the deficiency is to be corrected, on both a temporary and

permanent basis2. The date the correction will be completed3. The name, title, and/or position of the person responsible for

implementing the corrective action4. A description of the monitoring system you will use to prevent the

deficiency from recurring5. The signature, title, and date signed of the person responsible for

the POC on the first page of the SOD



• Please follow the steps stated on the cover letter to complete the POC process. Call your surveyor if you have questions

• You can find a copy of the SOD cover letter with a sample POC on our website: http://azdhs.gov/licensing/residential-facilities/index.php




Plan of Correction (“POC”)• Return the signed SOD with the POC to the

Department. Include any supporting documentation, pictures, etc., as proof that you have made the necessary corrections

• Keep a copy for your records. You must make the SOD and POC available to the public

• Late POC’s– Get them in on time!– Late letters will be sent and could lead to further

enforcement action– No extensions

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Plan of Correction (“POC”)• Your surveyor will review your POC • Acceptable POC’s – If it is acceptable, the surveyor will recommend closing

the survey• Unacceptable POC’s– You will receive a letter detailing what is missing– Read the letter; if it was unacceptable, it means the POC

didn’t meet one of the requirements in the SOD letter– Call your surveyor if you aren’t sure what it means



• Depending on the circumstances, the surveyor may do an onsite follow-up inspection to ensure all deficiencies are corrected before closing the inspection• Reminder: Your survey results and POC

is public record

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POC vs. IDR• If you wish to use the Informal Dispute

Resolution (“IDR”) process to have deficiencies changed or removed, your IDR must be separate from your POC and sent to Diane Eckles, Bureau Chief

• The POC must include all deficiencies, even those for which you are filing an IDR

• A POC which includes language that disputes that the deficiency occurred, or does not address a deficiency will be returned to you as unacceptable


Informal Dispute Resolution

• Referred to as an IDR• The IDR process is described on our website: http://

azdhs.gov/als/residential/documents/informal-dispute-resolution-process.pdf

• The purpose of an IDR is to show the facility was in compliance at the time of inspection

• It is not a guarantee a deficiency will be removed just because you disagree

• It has to be legitimate and specific to the citation

http://azdhs.gov/als/residential/documents/informal-dispute-resolution-process.pdf





Top DeficienciesTop 10 deficiencies 07/01/2014 through 04/30/2015 for Behavioral

Health Residential Facilities

1. R9-10-707.A.12.a-b: Admission; Assessment2. R9-10-722.B.5.a: Physical Plant Standards3. R9-10-707.A.5: Admission; Assessment4. R9-10-708.A.5: Treatment Plan5. R9-10-720.B.4: Emergency and Safety Standards6. R9-10-708.A.4.c: Treatment Plan7. R9-10-707.A.7.a: Admission; Assessment8. R9-10-708.A.2.b: Treatment Plan9. R9-10-721.A.10: Environmental Standards10. R9-10-722.B.8.g.ii.(2): Physical Plant Standards


Top DeficienciesTop 10 deficiencies 07/01/2014 through 04/30/2015 for Assisted Living

Facilities

1. R9-10-816.B.3.b: Medication Services2. R9-10-819.A.11: Environmental Standards3. R9-10-807.B.1.a-b: Residency and Residency Agreements4. R9-10-818.A.4: Emergency and Safety Standards5. R9-10-811.C.17: Medical Records6. R9-10-819.A.1.b: Environmental Standards7. R9-10-816.F.1: Medication Services8. R9-10-818.F.4.a.i-iv: Emergency and Safety Standards9. R9-10-808.C.1.g: Service Plans10. R9-10-806.A.7.a-b: Personnel


Treatment Plans vs Service Plans• Treatment Plans = Article 7, Behavioral Health

Residential Facilities– Article 1 definition: “Treatment plan” means a description of

the specific physical health services or behavioral health services that a health care institution anticipates providing to a patient

• Service Plans = Article 8, Assisted Living Facilities– Article 8 definition: “Service plan” means a written

description of a resident’s need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident


Treatment Plans• R9-10-708 - An administrator shall ensure a

treatment plan is:• Developed and implemented for each resident that is based on

the medical history and physical examination or nursing assessment and the behavioral health assessment and on-going changes to the behavioral health assessment

• Completed by a BHP or a BHT receiving clinical oversight (BHPP’s cannot develop a treatment plan)

• Completed before the resident receives behavioral health services or within 48 hours after the assessment is completed

• Treatment plans are updated according to the review date or when the assessment changes

• SPECIFIC TO THE RESIDENT! NO TWO RESIDENTS ARE ALIKE


Resident is admitted.

Behavioral health assessment is

completed.

BHP reviews assessment.

Physical health & ancillary

services begin.

Treatment plan completed

BHP reviews treatment

plan.

Within 48 hours of admission & filed in the

medical record

Within 24 hours of completion.

Within 48 hours of completion of assessment & filed in the

medical record.

Within 24 hours of completion of treatment plan.

Behavioral health services begin


Service Plans• R9-10-808, R9-10-814.F, and R9-10-815.C: Lists service plan requirements

depending on resident’s level of care• Key item: Amount, type, and frequency of services! • Developed with assistance and review from the resident or resident’s

representative, the manager, and individual requested by the resident or resident’s representative

• If a resident requires intermittent nursing services or medication administration, must be reviewed by a nurse or medical practitioner

• Completed no later than 14 calendar days after the resident’s date of acceptance• Updated no later than 14 calendar days after a significant change in the

resident’s physical, cognitive, or functional condition AND– Once every 12 months for a resident receiving supervisory care services– Once every 6 months for a resident receiving personal care services– Once every 3 months for a resident receiving directed care services

• SPECIFIC TO THE RESIDENT! NO TWO RESIDENTS ARE ALIKE


Medication Services• Behavioral Health Residential: R9-10-718

• Assisted Living Facilities: R9-10-816

• Facilities must have policies and procedures!


Self-Administration of Medication

• R9-10-101.184 Definition: “Self-Administration of Medication” means a patient having access to and control of the patient’s medication and may include the patient receiving limited support while taking the medication

– Facility does not lock or store medication; resident must have access at all times

– Limited support may include:• General reminders to take medication or asking if resident had taken

medications that day• Retrieving medication containers for the resident or opening the

medication container, if the resident is physically unable and requests the assistance


Assistance in the Self-Administration of Medication

• R9-10-101.17 Definition: “Assistance in the self-administration of medication” means restricting a patient’s access to the patient’s medication and providing support to the patient while the patient takes the medication to ensure the medication is taken as ordered


Assistance in the Self-Administration of Medication continued

The following assistance is provided to a resident: a. A reminder when it is time to take the medication; b. Opening the medication container for the resident; c. Observing the resident while the resident removes the medication from the

container; d. Verifying that the medication is taken as ordered by the resident’s medical

practitioner by confirming that: i. The resident taking the medication is the individual stated on the medication

container label, ii. The resident is taking the dosage of the medication stated on the medication

container label or according to an order from a medical practitioner dated later than the date on the medication container label, and

iii. The resident is taking the medication at the time stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label; or

e. Observing the resident while the resident takes the medication;


Medication Administration

• R9-10-101.120 Definition: “Medication Administration” means restricting a patient’s access to the patient’s medication and providing the medication to the patient or applying the medication to the patient’s body, as ordered by a medical practitioner


Medication Administration continued

Medication must be stored by the facility• Policies and procedures must exist• Administered to a resident:– Is administered in compliance with a medication

order, and – Is documented in the resident’s medical record


Medication Storage• BH Residential: R9-10-718.E• AL Facilities: R9-10-816.F

Medications stored a the facility:• Medication is stored in a separate locked room, closet, cabinet, or self-contained unit

used only for medication storage• Medication is stored according to the instructions on the medication container• Policies and procedures must be established, documented, and implemented:

– Receiving, storing, inventorying, tracking, dispensing, and discarding medication, including expired medication;

– Discarding or returning prepackaged and sample medication to the manufacturer if the manufacturer requests the discard or return of the medication;

– A medication recall and notification of the residents who received recalled medication; and

– Storing, inventorying, and dispensing controlled substances


Drug and Toxicology Reference GuidesR9-10-718.D (BH Residential) & R9-10-816.D (AL Facilities)

1. A current drug reference guide is available for use by personnel members, and2. A current toxicology reference guide is available for use by personnel members

– These references can be “online,” as long as they are available at all times.

– A common toxicology reference is TOXNET, which can be found at: http://toxnet.nlm.nih.gov/

– Current means the publication has not been updated and is not out-of-date (i.e. – 1982 PDR)

http://toxnet.nlm.nih.gov/

http://toxnet.nlm.nih.gov/


Renewal Application• The Department mails renewal reminder

postcards as a courtesy, but you are responsible for ensuring that your renewal application is submitted on time

• When a completed renewal application and all fees are received, the Department will mail you your new license. Hang the original license on the wall

45


Compliance Team

• Not a comprehensive list, but common items referred for Enforcement Action:– Late applications– Repeat/uncorrected deficiencies– Fingerprinting– Personnel issues (CPR/FA, training)– Residents left alone


Late Applications

• Renewal applications are due to the Bureau no later than 60 days prior to the expiration date on the license

• An application received 59 or fewer days prior to the license expiration date will result in the assessment of a civil penalty of $250.00 for a first offense

• Subsequent offenses will result in higher penalties


Late Applications• If an application is not received prior to the

expiration date of the license, the facility may be considered closed

• If such a facility is still providing services, enforcement action may be taken, as the facility is considered to be providing unlicensed care


Repeat/Uncorrected Deficiencies

• After any survey and deficiencies are cited, a plan of correction is expected

• Once the plan of correction is received, reviewed, and accepted, the deficiency should NOT be found at or during the next inspection

• If it is, it is a repeat or uncorrected deficiency


Fingerprinting

• Fingerprint Statutes– A.R.S. 36-411– A.R.S. 36-425.03 (Specific to Behavioral Health

Residential Facilities providing services to children)• Direct care staff in all facilities must have

fingerprint clearance– BH residential facilities who serve children have a

more restrictive requirement


Personnel Issues• CPR/First Aid Training: No staff onsite have

current CPR/First Aid training• Non-caregivers: For Assisted Living and BH

residential authorized to provide Personal Care services– Leaving a resident with a volunteer, staff, or

individual who does not have Caregiver training approved through the NCIA Board


Residents left alone

• Believe it or not, it has happened• Residents left alone with no supervision• Going around the corner to a next door house or

facility doesn’t count as being on premises• All subclasses require AT LEAST one personnel

member present at the facility when there is a resident– Many facilities require personnel to be awake, some

don’t, check your rules!


QUESTIONS?• Phoenix office: 150 N. 18th Ave., Suite 420 • 602-364-2639 FAX: 602-324-5872

• Tucson office: 400 W. Congress St., Suite 116 • 520-628-6965 FAX: 520-628-6991

• Website: http://azdhs.gov/licensing/residential-facilities/index.php

• Email: [email protected]


mailto:[email protected]


Thank you!

health and wellness for all arizonans maintaining compliance in residential facilities

Documents

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arizonans rules

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arizonans applicable

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