state of assisted living mid year 2016 … 03, 2017 · state of assisted living mid year 2016...

P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance

Wisconsin Department of Health Services

STATE OF ASSISTED LIVING Mid Year 2016

November 8, 2016



Agenda 1. BAL Staffing

2. Trends and Statistics

Assisted Living (AL) Capacity

AL Complaints

AL Self-Reports

AL Survey

Abbreviated Surveys

AL Enforcement

Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL)

3. Bureau of Assisted Living Strategies

4. Wrap-Up



Bureau of Assisted Living Staffing

Assisted Living Regional Directors

• Northeastern Regional Office (NERO)

oKathy Lyons

• Western Regional Office (WRO)

oWilliam Gardner

• Southern Regional Office (SRO)

o Linda Boswell

• Southeastern Regional Office (SERO)

oMichelle Crockett



Quality Assurance Program Specialists, Senior

• Lynnette Traas

• Cindy O’Connell

• Vacant, Enforcement Specialist




Central Office Staff

• Colette Anderson, Research Technician

• Damon Scott, Office Operations Program Associate

• Lori Smithback, Central Licensing Associate

• Chquota Carter, Central Health Service Specialist




Assisted Living Support Staff

• Southern Regional Office

o Thom Smith

o Julie Mallder

• Western Regional Office

o Moua Luedtke

o Vacant

• Southeastern Regional Office

o Rothea Hunt

o Maxine Johnson

• Northeastern Regional Office

o Diane Van Rens

o Carrie Raasch




Assisted Living Surveyors

Northeastern Regional Office

o Jerome Riederer

o Heather Schweiner

o Phyllis Witter

o Jule Degrave

o Connie Van Rossum

o Trisha Piotraschke

o Cari Gast

o Vicky Whittman

o Sandra Culligan

o Nicole Hall





Southeastern Regional Office

o Bunny Booker

o MaryBeth Hoffman

o Sharon Gries

o Connie Knezic

o Tom Redding

o Geralyn Spitzer

o Joelle Verstegen

o Cindie Wilbur

o Kelly Clark






Western Regional Office

o Cynthia Larson

o Sandy Finseth

o Mary Eckwright

o Ann Colbenson-Hallum

o Kris Carew

o Judy Jordan

o Kelly Haugen

o Ron Kunferman




Southern Regional Office

o Cheryl Bott

o Leann Fox

o Cindy Lindgren

o Tina Lubick

o Roda McLees

o Estrella Schnering

o Sharon Paulson

o Shannon Lane




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



Wisconsin Assisted Living Facilities

•Wis. Admin. Code ch. DHS 88

•Wis. Stat. ch. 50





•Adult Day Standards

Adult day care

Community-based

residential facility

Adult family home

Residential care

apartment complexes



Regulatory Trends



Regulatory Trends • Increase in:

o Number of Assisted Living Facilities

o Resident Acuity

Health monitoring

Behavioral monitoring

Care planning/Assessment

o Lack of Qualified Staff

Administrator/Service Managers

Training not provided

o Financial Difficulties

o Lack of Systems of Care



Regulatory Trends

• As a result, BAL sees:

o Testing the “boundaries” of Assisted Living care

o Complex complaints

o Serious outcomes to resident

o Limited/No action by provider

o Failure to sustain compliance

o Increased enforcement activity

Revocations

Directed Plan of Correction (DPOC)

Forfeitures



Assisted Living Facilities

0

1000

2000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

RCAC 152 171 188 203 218 245 271 278 295 303 308 313 320 327AFH 765 834 965 1049 1130 1185 1273 1392 1467 1544 1621 1759 1835 1943CBRF 1352 1367 1372 1382 1403 1429 1458 1470 1476 1501 1514 1522 1536 1584

Num

ber o

f Com

mun

ities

Trend in Number of Facilities



Assisted Living Capacity

0

10000

20000

30000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

AFH 2964 3217 3727 4054 4358 4585 4916 5430 5730 5987 6285 6815 7105 7516RCAC 6055 6614 8003 8980 9562 10579 11988 12330 13176 13580 14069 14338 14552 14966CBRF 21392 21739 21996 22408 22822 23490 24366 24765 25201 25985 26750 27597 28414 29520

Capa

city

Trend in Assisted Living Capacity



Assisted Living vs. LTC Facilities

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

AL 2269 2372 2525 2634 2751 2859 3001 3238 3348 3348 3577 3727 3881 3989LTC 444 439 436 425 421 415 413 413 413 410 411 405 403 399

0

500

1000

1500

2000

2500

3000

3500

4000

Num

ber

of F

acil

itie

s




Assisted Living vs. LTC Capacity

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

LTC 4305242074410104005439296385963754636961365693576035359344633443333910AL 3041131570337263544236742386544127042525441074555251158527195438356484

0

10000

20000

30000

40000

50000

60000

Cap

acit

y

Trend in Capacity for Residents



Nursing Home and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

FIDs 37 35 32 22 19 16 14 14 13 13 12 10 7 7NHs 407 404 404 403 402 399 399 399 400 397 399 395 396 392

050

100150200250300350400450

Num

ber o

f Fac

ilitie

s

Year




Nursing Home and ICF/IID

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun2016

FIDs 2,391 2,115 1,734 1,354 1,190 1,102 989 939 908 768 720 577 540 539NHs 40,661 39,959 39,276 38,700 38,106 37,494 36,557 36,022 35,661 34,992 34,639 33,886 33,893 33,731

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Resi

dent

Cap

acity

Year

Trend in Capacity for Residents



Residential Care Apartment Complex (RCAC)

0

100

200

300

400

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

Registered 67 77 84 88 93 100 97 94 99 99 98 93 96 97Certified 86 94 104 115 125 147 174 184 196 204 210 220 224 230Total 153 171 188 203 218 247 271 278 295 303 308 313 320 327

Num

ber o

f RCA

C

Year P-01726 (12/2016)



Adult Day Care (ADC) Centers

0

20

40

60

80

100

120

140

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015ADC 101 105 106 97 102 114 115 121 128 134 134 133 140

Num

ber o

f AD

C

Year

Trend in Number of Centers



Adult Day Care Centers

0

1,000

2,000

3,000

4,000

5,000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

ADC 2,526 2,578 2,582 2,617 2,770 3,101 3,097 3,407 3,471 3,874 4,054 3,969 4,234 4,482

Capa

city

Year

Trend in the Capacity for Participants



Assisted Living Complaints Mid Year 2016



Assisted Living Complaints Received

0

200

400

600

800

1,000

1,200

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

# complaints 792 667 677 718 681 774 836 789 801 916 900 981 1,117 549

Num

ber o

f Com

plai

nts

Year



Complaints Received Mid Year 2016

2%

23%

66%

9%

Complaints ADC AFH CBRF RCAC

P-01726 (12/2016)



Percentage of Facilities with Complaints Submitted

9.9%

90.1%

% of Facilities withComplaints Submitted% of Facilities with NoComplaints



Source of Complaint Mid Year 2016

44%

11%

25%

2% 3%

3% 4% 5% 3%

AnonymousPublic OfficialRelative or GuardianCurrent EmployeeFormer EmployeeMedicalCitizenResidentAdvocate



Assisted Living Self-Reports Mid Year 2016



Self-Reports Received

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

1,166 1,452

1,856 1,872

2,751

3,446 3,271

3,534 3,343

3,645 4,058

1,766

Tota

l Num

ber

Year



Self-Reports Received Mid Year 2016 (1,766)

16% 0%

84%

Self-Reports Open Investigation Review Next Visit File



Number of Self-Reports by Subject Area

53%

9% 7%

7%

10%

6% 3% 2% 1% 1% 0% 1%

Mid Year 2016 Falls Resident Behavior PoliceElopement Hospital (Not Fall) OtherMisappropriation Abuse NeglectFire Communicable Disease Disaster or Evacuation



99%

1%

Self-Reports Investigated Mid Year 2016 (475)

No SOD SOD

(SOD = Statement of Deficiency)



Abbreviated Surveys Mid Year 2016

• No deficiency survey - 59%

• Statement of deficiency - 41%



Facilities Qualifying for Abbreviated Surveys Mid Year 2016

• Adult day care 68.1% • Adult family home 47.7% • Community-based residential facility 44.9% • Residential care apartment complex 58.2%

• Statewide 48.1%



Facilities Qualifying for an Abbreviated Survey

0%

10%

20%

30%

40%

50%

60%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

% Abbr. Surveys 37.2% 37.9% 38.2% 40.5% 39.3% 42.4% 45.7% 46.7% 46.8% 50.8% 53.5% 49.1% 47.7%48.10%

% o

f Tot

al F

acili

ties

Year



Statewide Survey Results

0%10%20%30%40%50%60%70%

No Citations SOD Only Surveys withEnforcement

2007 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 excludes initial & CHOW 55% 11% 33%2015 60% 10% 27%Jun-16 63% 11% 26%

% o

f To

tal S

urve

ys



2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Jun2016

Total Citations 2,421 2,625 2,569 2,759 2,369 2,417 2,623 2,471 2,420 2,091 2,423 2,437 1,014Average per Survey with Citation 3.3 3.3 3.7 3.3 3 2.9 3.4 3.6 3.3 3.2 2.5 3 2.9

0

0.5

1

1.5

2

2.5

3

3.5

4

0

500

1,000

1,500

2,000

2,500

3,000

Ave

rage

Cit

atio

ns p

er S

urve

y w

ith

Cit

atio

ns

Year

Tot

al C

itat

ions

Assisted Living Citations Issued



CBRF Top Ten Citations June 2016

0

5

10

15

20

25

Number of Citations83.35(3)d SERVICE PLANS UPDATED ANNUALLY OR

ON CHANGES 25

83.47(2)e Other evacuation drills 2383.12(5)a Notification: Incident, Injury, Changes 1783.43(1) ENVIRONMENT SAFE, CLEAN, AND

COMFORTABLE 16

83.20(2)c TRAINING IN FIRST AID AND CHOKING 1683.32(3)h Rights of Residents: to Receive medication 1583.15(3)a Adminstrator shall supervise daily

operation 13

83.20(2)b Training in Fire Safety 1383.38(1)g Health Monitoring 1383.32(3)i Rights of Residents: prompt and adequate

treatment 12

Citation



Top Ten Cites With Forfeiture CBRF Mid Year 2016

$24,600.00

$17,300.00

$13,950.00

$13,600.00

$13,380.00

$12,900.00

$10,850.00

$10,000.00

$7,370.00

$7,000.00

CAREGIVER: INVESTIGATING ABUSE ANDNEGLECT

NOTIFICATION: INCIDENT, INJURY, CHANGES

ADMINISTRATOR SHALL SUPERVISE DAILYOPERATION

RIGHTS OF RESIDENTS: FREE OF MISTREATMENT

RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION

RIGHTS OF RESIDENTS: PROMPT AND ADEQUATETREATMENT

IMPLEMENT, FOLLOW THE INDIVIDUAL SERVICEPLAN

SERVICE PLANS UPDATED ANNUALLY OR ONCHANGES

SUPERVISION

HEALTH MONITORING

$0 $20,000 $40,000

Cit

atio

n

Total Forfeiture Amount



AFH Top Ten Citations Mid Year 2016

0

5

10

15

20

25

30

Number of Citations88.05(3)a HOME ENVIRONMENT 2788.05(4)(d)2.b FIRE EVACUATION ANNUAL

EVALUATION 21

88.07(3)a Prescription Medications 2088.04(2)a Responsiblities 1588.05(4)(b)2 SMOKE DETECTORS-TESTING AND

MAINTENANCE 14

88.07(3)€1 Medication-Record Keeping 1388.04(5) Training-15 Hours within 6 months 1288.05(4)(b)1 Fire Safety-Smoke Detectors 1288.10(3)i SAFE PHYSICAL ENVIRONMENT 1288.10(3)i SAFE PHYSICAL ENVIRONMENT

Citation



RCAC Top Ten Citations Mid Year 2016

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Number of Citations89.23(4)(a)2 SERVICES 2

89.28(1) RISK AGREEMENT 2

89.28(5) RISK AGREEMENT 1

89.34(16) TENANT RIGHTS 1

89.26(3)(a) PARTICIPATION IN THEASSESSMENT 1

89.27(3)(d) SERVICE AGREEMENT 1

89.27(4) SERVICE AGREEMENT 1

89.23(2)(a)2.c SERVICES 1

Citation



ADC Top Ten Citations Mid Year 2016

0

1

2

3

Number of CitationsII.a.(4) PERSONNEL-HEALTH

EXAMINATION 3

III.b.(5) SAFETY-EMERGENCIES PLAN 3

II.d.(2) TRAINING-ORIENTATION. 3

II.d.(3) TRAINING-EMPLOYEES 2

I.f.(3)(c) MEDICATION-LOCKED SAFEPLACE 2

II.a.(2) PERSONNEL-BACKGROUNDVERIFICATION 2

III.a.(6) SANITATION-MANUAL WASHING 1

I.c.(4) PLAN-QUARTERLY DOCUMENTING 1

I.c.(3) PLAN-REVIEWED & UPDATEDEVERY 6 MONTHS 1

I.a.(1) PROGRAM ADMINISTRATION-DESCRIPTION 1

III.b.(4) SAFETY-DRINKING WATER 1

Citation



Assisted Living Enforcement Mid Year 2016



0

100

200

300

400

500

600

2003 2004 2005 2006 2007 2008 2009 20094

YearEntity

2010 2011 2012 2013 2014 20144

YearEntity

2014SmallClass

C

2015 Jun-16

Enforcements 471 442 409 475 546 474 444 42 522 475 421 439 410 240 46 484 284

Enfo

rcem

ent S

urve

ys

Year

AL Surveys With Enforcement



0

20

40

60

80

100

120

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Jun-16

44

57 49

105

89 82 78 82

61

79

58

20

No

New

Adm

issi

on O

rder

s

Year

Assisted Living No New Admission Orders



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 2015 Jun-16

$439,406

$547,300

$433,055

$614,952

$422,530

$608,989

$889,925

$816,600

$979,313 $1,036,165

$886,555

$255,155

Forf

eitu

re A

sses

smen

ts

Year



Percentage of Facilities Receiving Enforcements Mid Year 2016

5.7%

94.3%

% FacilitiesReceivingEnforcement% Facilities WithNo Enforcements



Assisted Living Surveys with Citations with Appeals Mid Year

2016

98%

2%

Surveys With CitationsAppeals



Bureau of Assisted Living Strategies



2016-2017 BAL Initiatives • Completion of LEAN Application Project

• Abbreviated initial licensing process • Templates • BAL staffing • Revision letters/2x • Website redesign

• E-Licensure/E-Payment System • License renewal • Initial licensing/certification



2016-2017 BAL Initiatives

• Evaluation of the Assisted Living Survey Enforcement system

• Transitions in Care Coordination Workgroup • Home & Community Based Services (HCBS)

validation reviews • Strategies to enhance resident care publication(s) • Concentrated Survey Activities • Supporting Older Adults with Intellectual

Disabilities (ID) online training course • http://continuingstudies.wisc.edu/classes/supporti

ng-older-people-intellectual-disabilities

http://continuingstudies.wisc.edu/classes/supporting-older-people-intellectual-disabilities

http://continuingstudies.wisc.edu/classes/supporting-older-people-intellectual-disabilities



Wisconsin Coalition for Collaborative Excellence in Assisted

Living (WCCEAL)



Wisconsin Coalition for Collaborative Excellence in

Assisted Living

• Provider association sponsored

• Department approved

• Comprehensive quality assurance (QA) and quality improvement (QI)



Internal Quality Assurance

• Essential to maintain quality!

• Structure, process, and outcome measures used to evaluate quality



WCCEAL Regulatory Data Mid Year 2016



CBRFs AFHs RCACs WCCEAL Assisted Living

Communites 254 39 100

0

50

100

150

200

250

300N

umbe

r of F

acili

ties

WCCEAL Regulated Facilities Mid Year 2016



WCCEAL Regulated Facilities Surveys Conducted

Total Surveys Surveys WithCitations

Total CitationsIssued

Surveys With NoCitations

Jun-16 136 52 110 84

020406080

100120140160

Num

ber o

f Sur

veys

Mid Year 2016



WCCEAL Members Complaints Mid Year 2016

Total Facilities 393Total Complaints 81Facilities With Complaints 54

050

100150200250300350400450



WCCEAL Regulated Facilities Qualifying for Abbreviated Surveys

Mid Year 2016

Total Number of Facilities 393Qualifying Facilities 231RCAC 80CBRF 124AFH 27

050

100150200250300350400450



WCCEAL Regulated Facilities Abbreviated Survey Results

Mid Year 2016

Total Abbreviated Surveys 21Surveys With No Citations 14Surveys With Citations Only 7Enforcement Action 5

0

5

10

15

20

25



Percentage of Facilities with Complaints Mid Year 2016

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

13.7% 9.6%

% o

f Fac

ilitie

s W

ith C

ompl

aint

s

WCCEAL Non-WCCEAL



Average Citations per Survey with Citations Mid Year 2016

2

2.2

2.4

2.6

2.8

3

3.2

2.1

3

Num

ber o

f Cita

tions

WCCEAL Non-WCCEAL



Life is like a camera, focus on what’s important and you will capture it perfectly. (author unknown)



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/

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