STATE OF ASSISTED LIVING Calendar Year 2018 March 12, 2019 · P-01726 (03/2019) Promoting Regulatory Compliance Division of Quality Assurance 1 Wisconsin Department of Health Services

P-01726 (03/2019) Promoting Regulatory Compliance Division of Quality Assurance 1

Wisconsin Department of Health Services

STATE OF ASSISTED LIVING Calendar Year 2018

March 12, 2019



Agenda 1. Trends and Statistics

Assisted Living (AL) Capacity

AL Complaints

AL Self-Reports

AL Survey

Bureau of Assisted Living Surveys

AL Enforcement

Wisconsin Coalition for Collaborative Excellence in Assisted Living (WCCEAL)

2. Bureau of Assisted Living Initiatives

3. Wrap-Up



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



Assisted Living Trends Provider Growth Continues:

o Adult Family Home (AFH) Operators

o Larger Community-Based Residential Facilities

o Change of Ownership

Plan of Correction

o Providers failing to submit plans of correction

Complaints:

o Number of complaints are on the rise.

o Increase in complaints from medical professionals.

Citations:

Facility Closures:

o Community-Based Residential Facility (CBRF) or Adult Family Home (AFH) closing or selling

P

rovi

der

Gro

wth

Com

plai

nts

Clo

sure

s

Pla

n of

Cor

rect

ion



Regulatory Trends Licensing/Certification:

• Common Assisted Living Application o Adult Family Home

o Plan Review

o Accessibility Requirements

o Program Statement

o Admission Agreement

o Evidence of Operation for 60 Days

o Background Check Process



Regulatory Trends Client Groups Served

• AFH o Intellectual Disability

o Mental Illness

o Advanced Age

o Irreversible Dementia/Alzheimer’s Disease

• CBRF o Advanced Aged

o Irreversible Dementia/Alzheimer's Disease

o Intellectually Disability

o Mental Illness

Affiliated vs Single Operator • More Assisted Living Facilities are Affiliated



Regulatory Trends Complaints

• Complaint Subject Areas o Program Services

o Physical Environment

o Resident Rights

o Staff Training and Proficiency

• More Complaints for Affiliated Provider vs Single Operator Provider

• Facilities Receiving More than 3 Complaints in Calendar Year

• Highest Source of Complaint is Anonymous and Relative/Guardian/POA-HC



Assisted Living Facilities Trends in Facility Number

2014 2015 2016 2017 2018

ADC 135 131 127 129 127RCAC 313 320 342 331 341CBRF 1,522 1,536 1,620 1,597 1,601AFH 1,759 1,835 2,061 1,995 2,010

0

500

1,000

1,500

2,000

2,500

Num

ber

of F

acil

itie

s



Assisted Living Capacity Trends in Facility Capacity

2014 2015 2016 2017 2018ADC 4,309 4,232 4,347 4,259 4,339AFH 6,815 7,105 7,983 7,904 7,771RCAC 14,338 14,552 15,583 15,460 15,847CBRF 27,597 28,414 30,653 31,125 31,761

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Num

ber

of B

eds



Residential Care Apartment Complex Trends in Registered or Certified Facilities

2014 2015 2016 2017 2018

Registered 93 96 100 94 92Certified 220 224 242 237 249Total 313 320 342 331 341

0

50

100

150

200

250

300

350

400

Num

ber

of F

acil

itie

s



Assisted Living vs. LTC Facilities Trends in Facility Number

2014 2015 2016 2017 2018

AL 3,727 3,881 4,166 4,052 4,079LTC 405 403 397 388 387

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

Num

ber

of F

acil

itie

s



Assisted Living vs. LTC Capacity Trends in Facility Capacity

2014 2015 2016 2017 2018

LTC 34,463 34,433 33,205 32,236 31,321AL 52,719 54,383 59,224 58,748 59,718

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Num

ber

of B

eds



Assisted Living Ownership Types

Corporation - Business (27.1%)

Corporation – Non-Profit

(13.9%)

Proprietorship (7.5%)

Partnership (1.6%)

Church (1.2%)

County Gov’t (0.8%)

Other (0.7%)

Other Gov’t (0.1%)

State Gov’t (0.1%)

Tribal (0.1%)

Limited Liability Company (46.5%)



Ownership-AFH



Corporation - Non-Profit (8.7%)


Partnership (2.7%)

Church (0.4%) Other (1.0%)

County Gov’t (0.3%) State Gov’t (0.3%)



Ownership-CBRF



Corporation - Non-Profit

(17.1%)


County Gov’t (1.0%)

Partnership (0.5%) Church (0.7%)

Other Gov’t (0.3%) Tribal (0.2%) Other (0.2%) State Gov’t (0.1%)



Ownership-ADC




Church (14.1%)


County Gov’t (5.6%) Other (3.5%) Other Gov’t (0.7%) Partnership (0.7%)



Ownership-RCAC



Corporation – Business (14.0%)

County Gov’t (1.3%) Partnership (0.5%) Other (0.5%) Proprietorship (0.2%) Other Gov’t (0.2%) State Gov’t (0.2%)

Church (3.2%)



Affiliated Assisted Living Facilitates

ADC AFH CBRF RCAC

Affiliated 38% 59% 78% 75%Independent 62% 41% 22% 25%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% A

ffil

iate

d



Assisted Living Facility Closures

Voluntary (40.8%)

Change of Ownership (24.0%)

Other (22.9%)

Revocation (6.1%) RCAC Conversion (1.6%) CBRF Conversion (1.4%) Change Location (1.1%) Non-Renewal (0.8%) AFH Conversion (0.8%)



Assisted Living Complaints Calendar Year 2018



Assisted Living Complaints Received

2014 2015 2016 2017 2018

# complaints 981 1,117 1,207 1,290 1,465

0

200

400

600

800

1,000

1,200

1,400

1,600

Num

ber

of C

ompl

aint

s



Complaints Received CY 2018

CBRF (65.8%)

RCAC (10.7%)

ADC (0.3%)

AFH (23.0%)



Source of Complaint CY 2018

39%

8%

28%

2%

4%

4%

4%

9% 2%

AnonymousPublic OfficialRelative or GuardianCurrent EmployeeFormer EmployeeMedicalCitizenResidentAdvocate



Complaints vs. Growth

2014 2015 2016 2017 2018

# complaints 981 1,117 1,207 1,290 1,465# AL Facilities 3,727 3,881 4,166 4,052 4,079

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500



Percentage of Facilities with Complaints Submitted

20.3%

79.7%

% of Facilities withComplaints Submitted% of Facilities with NoComplaints



Assisted Living Self-Reports Calendar Year 2018



Self-Reports Received

2014 2015 2016 2017 2018Self Reports 3,645 4,058 4,473 4,844 5,284

0

1,000

2,000

3,000

4,000

5,000

6,000

Num

ber

Rec

eive

d



Self-Reports Received CY 2017

Open Investigation FileTotal: 5,284

94.4%

5.6%



Number of Self-Reports by Subject Area

54%

6%

10%

7%

10%

8%

2% 1%

1%

0.1%

0.1%

1%

FallsResident BehaviorPoliceElopementHospital (Not Fall)OtherMisappropriationAbuseNeglectFireCommunicable DiseaseDisaster or Evacuation



No SOD 72%

SOD 28%

Self Reports Investigated



Findings of Self Report Investigation by Type of Violation

20%

28%

11%

4%

4%

6%

10%

2%

5%

10%

ElopementFall-HospitalizationPolice InterventionAbuseMisappropriationNeglectResident BehaviorFireHospitalizationOther



Bureau of Assisted Living Surveys Calendar Year 2018



Abbreviated Surveys CY 2018

No Deficiency Survey - 59%

Statement of Deficiency - 41%



Facilities Qualifying for Abbreviated Surveys

Adult Day Care 63%

Adult Family Home 49%

Community-Based Residential Facility 45%

Residential Care Apartment Complex 58%

Statewide 48%



Facilities Qualifying for an Abbreviated Survey

2014 2015 2016 2017 2018% Abbr. Surveys 49.1% 47.7% 46.1% 49.0% 48.0%

45%

46%

47%

48%

49%

50%

% o

f T

otal

Fac

ilit

ies



Statewide Survey Results

No Citations SOD Only Surveys with Enforcement2014 55% 11% 33%2015 60% 10% 27%2016 63% 11% 26%2017 53% 15% 32%2018 61% 13% 26%

0%

10%

20%

30%

40%

50%

60%

70%



2014 2015 2016 2017 2018

Total Citations 2,423 2,437 2,719 3,118 3,810Average per Survey with Citation 2.5 3 3.3 2.8 3

0

0.5

1

1.5

2

2.5

3

3.5

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Ave

rage

Cit

atio

ns p

er S

urve

y w

ith

Cit

atio

ns

Tot

al C

itat

ions

Assisted Living Citations Issued



CBRF Top Ten Citations

01020304050607080

Number83.35(3)(d) SERVICE PLANS UPDATED ANNUALLY OR

ON CHANGES 71

83.47(2)(e) OTHER EVACUATION DRILLS 4683.32(3)(h) RIGHTS OF RESIDENTS: TO RECEIVE

MEDICATION 42

83.43(1) ENVIRONMENT SAFE, CLEAN, ANDCOMFORTABLE 41

83.15(3)(a) ADMINISTRATOR SHALL SUPERVISE DAILYOPERATION 32

83.38(1)(g) HEALTH MONITORING 3283.38(1)(b) SUPERVISION 3283.32(3)(i) RIGHTS OF RESIDENTS: PROMPT AND

ADEQUATE TREATMENT 30

83.47(2)(d) FIRE DRILLS 3083.35(3)(a) COMPREHENSIVE INDIVIDUALIZED

SERVICE PLAN 29

Citation



Top Ten Cites With Forfeiture CBRF

$70,800.00

$54,300.00

$51,830.00

$43,695.00

$40,200.00

$37,150.00

$32,200.00

$32,100.00

$26,050.00

$21,800.00

RIGHTS OF RESIDENTS: PROMPT AND ADEQUATETREATMENT

HEALTH MONITORING

SUPERVISION

RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION

SERVICE PLANS UPDATED ANNUALLY OR ONCHANGES

RIGHTS OF RESIDENTS: FREE OF MISTREATMENT

NOT PERMIT A CONDITION OF SUBSTANTIAL RISK

ADMINISTRATOR SHALL SUPERVISE DAILYOPERATION

NOTIFICATION: INCIDENT, INJURY, CHANGES

RESOURCES FOR DESTRUCTIVE ABUSIVERESIDENTS

$0 $20,000 $40,000 $60,000 $80,000

Cit

atio

n

Total Forfeiture Amount



AFH Top Ten Citations

01020304050607080

Number of Citations88.05(3)(a) HOME ENVIRONMENT 7588.07(3)(a) PRESCRIPTION MEDICATIONS 4788.04(2)(a) RESPONSIBILITIES 4588.04(5)(a) TRAINING-15 HOURS WITHIN 6

MONTHS 39

88.05(4)(d)2.b FIRE EVACUATION ANNUALEVALUATION 38

88.10(3)(l) SAFE PHYSICAL ENVIRONMENT 3688.06(3)(f) REVIEW OF ISP 3488.05(4)(b)2 SMOKE DETECTORS-TESTING AND

MAINTENANCE 33

88.04(5)(b) TRAINING-8 HOURS ANNUALLY 3288.07(3)(d) MEDICATION- WRITTEN ORDER 3088.04(2)(f) CONDITION WHICH REPRESENTS RISK

OR HARM 30

Citation



RCAC Top Ten Citations

0

1

2

3

4

5

6

7

8

Number89.23(4)(a)2 SERVICES 8

89.34(16) TENANT RIGHTS 7

89.23(4)(d)1 SERVICES 5

89.28(1) RISK AGREEMENT 5

89.23(2)(a)2.c SERVICES 3

89.27(3)(d) SERVICE AGREEMENT 2

89.28(5) RISK AGREEMENT 2

13.05(3)(a) ENTITY ALLEGATIONREPORTING REQUIREMENTS 2

89.23(4)(d)2.a SERVICES 2

89.23(4)(d)2.b SERVICES 2

89.23(2)(c) SERVICES 2

Citation



ADC Top Ten Citations

0

1

2

3

4

NumberII.d.(3) TRAINING-EMPLOYEES 4

II.d.(2) TRAINING-ORIENTATION. 4

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

II.a.(4) PERSONNEL-HEALTHEXAMINATION 3

I.c.(4) PLAN-QUARTERLY DOCUMENTING 2

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

II.a.(2) PERSONNEL-BACKGROUNDVERIFICATION 2

II.d.(4) TRAINING-CONTINUINGEDUCATION 2

III.a.(10)(a) SANITATION-FOOD STORAGE 1

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

III.a.(11) SANITATION-PREMISES CLEAN 1

Citation



Assisted Living Enforcement CY 2018



20142014 4

Year Entity2014 Small

Class C2015 2016 2017 2018

Enforcements 410 240 46 484 496 692 799

0

100

200

300

400

500

600

700

800

900

Num

ber

of S

urve

ys

AL Surveys with Enforcement



2014 2015 2016 2017 2018NNAO 79 58 52 50 31

0

10

20

30

40

50

60

70

80

90

Num

ber

of O

rder

s Assisted Living No New Admission Orders



Forfeiture Assessments

2014 2015 2016 2017 2018

Forfeiture $1,036,165 $886,555 $932,791 $519,340.00 $519,057

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

For

feit

ure

Ass

essm

ents



Enforcement Sanctions by Type

Comply POC (33%)

Comply Req. (31%)

Forfeiture (24%)

Other (7.0%) No Admission (3.0%) Revocation (2.0%) Accruing Forfeiture (0.1%) Deny (0.1%) Training (0.1%)



Percentage of Facilities Receiving Enforcements

13.7%

86.7%

% Facilities ReceivingEnforcement

% Facilities With NoEnforcements



Assisted Living Surveys with Citations and Percentage of Appeals

99%

1%

Surveys with Citations

Appeals



Bureau of Assisted Living Initiatives



Key Code (Core Areas)

Consumer Rights

Provision of Services / Quality of Care

Nutrition and Food Service

Physical Environment & Safety

Staff Training

Medication Management



Summary of BAL Initiatives Transition in Care Coordination Guide

-Nurse Practitioner Student Conducting In-Person/Webinar

Implementation of Home & Community Based Services (HCBS) into DQA/BAL Regulatory Program More Affiliated Assisted Living Providers Utilizing BAL E-Renewal System



BAL Future Initiatives Conduct Regional Assisted Living Forums

o Implement Assisted Living Consumer Town Halls

Examine/Develop Recommendations Regarding Health Services in Assisted Living

Study the Use of Technology in Assisted Living Facilities

BAL Going Green Initiatives o E-SOD o E-Renewal o E-Licensure o Self-Report o Increase Communication via Email and Other Technology o Increase the Use of Technology During Initial Licensing Surveys

Updates to Annual/ Biennial Reports

Promote Internal Quality Improvement Strategies within Assisted Living Facilities o Root Cause Analysis Techniques o Promote the Use of Resident Satisfaction Process within all Assisted Living Providers o Wisconsin Coalition for Collaborative Excellence in Assisted Living



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 CY 2018



CBRFs AFHs RCACs WCCEAL Assisted Living

Communites 226 47 109

0

50

100

150

200

250N

umbe

r of

Fac

ilit

ies

WCCEAL Regulated Facilities



Regulated Facilities Surveys Conducted

Total Surveys Surveys WithCitations

Total CitationsIssued

Surveys With NoCitations

2018 298 97 217 201

0

50

100

150

200

250

300

350

Num

ber o

f Sur

veys



WCCEAL Facilities Complaints

60%

26%

14%

FacilitiesComplaintsFacilities with complaints



WCCEAL Facilities Qualifying for Abbreviated Surveys

Total Number of Facilities 382Qualifying Facilities 229RCAC 85CBRF 115AFH 29

0

50

100

150

200

250

300

350

400

450



WCCEAL Facilities Abbreviated Survey Results

Total Abbreviated Surveys 80Surveys With No Citations 51Surveys With Citations Only 29Enforcement Action 7

0

10

20

30

40

50

60

70

80

90



Percentage of Facilities with Complaints

24.1% 21.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

% o

f F

acil

itie

s W

ith

Com

plai

nts

WCCEAL Non-WCCEAL



Average Citations per Survey with Citations

2.2 3.1

2

2.2

2.4

2.6

2.8

3

3.2

Num

ber

of C

itat

ions

WCCEAL Non-WCCEAL



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/

Documents

STATE OF ASSISTED LIVING Calendar Year 2018 March 12, 2019 · P-01726 (03/2019) Promoting Regulatory Compliance Division of Quality Assurance 1 Wisconsin Department of Health Services