Assisted Living Enforcement

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Assisted Living Enforcement

• September 2006

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Why Sanctions?Compel Compliance / Penalty

• CBRF Wis Stat chpt. 50.03(5g)
• AFH Admin Code HFS 88.03(g)
• RCAC Admin Code HFS 89.56
• ADC Standards

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Types of Sanctions Based on statutory
authority/admin rule

• Forfeitures (per day of violation)
• Orders
• No new admissions
• Training
• Directed Plans of Correction
• Stop Violating Requirement
• Revocation

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Enforcement Guidelines

• Legislative Audit Bureau
• Assisted Living Needs Enforcement Documentation
• Written Procedures (2003)
• Expansion
• Deferred/Impending Revocation
• Assisted Living Enforcement Guidelines
• http//dhfs.wisconsin.gov/rl_DSL/Providers/pde3200
  .pdf

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Citations to Refer for Enforcement

• Results in serious harm, potential serious harm,
  or systems problem
• Substantial probability that death or serious
  harm will result (or did occur)
• Direct threat to health, safety, welfare of a
  resident

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• Target Violations
• Inadequate supervision
• Inadequate staff to meet needs
• Minimum training requirements
• Life safety violations
• Smoke/heat detection
• Evacuation/emergency plans
• Safe building construction
• Inspection or service requirements
• Hot water temperatures

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• Abuse, neglect, misappropriation
• Resident rights
• Confinement
• Telephone/Visitors
• Decision-making
• Restraints
• Unfair treatment
• Criminal background checks
• Repeat violations or serious concerns

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• Prompt and Adequate Treatment
• Failure to provide services that contributes to
  adverse outcome
• Pressure sores
• Falls without intervention
• Pain that is not managed
• Weight loss
• Illness for which medical intervention is not
  sought
• Preventable injuries

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• Medications
• Residents do not receive medications
• Untrained staff administer medications
• Medications administered without proper medical
  authority
• Errors
• Activities
• Infection control, sanitation concerns

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• Financial instability
• Utility bills are not paid
• Staff are not paid
• Groceries are not purchased
• Repeat Violations

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Repeat Violations

• Uncorrected Cites (recited during VV)
• Tag cited on two consecutive surveys
• Corrected, but recited during next licensing
  survey
• facility was not able to maintain compliance

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SOD Enforcement Recommendation

• SOD forms basis for enforcement determination

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• Known risk factors
• Resident diagnoses
• Physical/cognitive limitations
• Environmental Factors (e.g., Climate)
• Structural concerns (door alarm off)
• History

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• Adverse outcomes
• Injury
• Hospitalization
• Fear/anxiety
• Pressure sore
• Weight loss
• Others?
• How residents are affected by the deficient
  practice?

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Enforcement Review and Determination

• Gravity
• Good Faith
• Previous Violations
• Financial Benefit
• Comparable sanctions imposed

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Extent and Seriousness

• Number of residents affected
• Degree of negative outcome
• Degree of potential outcome
• Period of Time (hours, days, weeks)
• Number of locations
• Isolated, pattern, widespread

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Gravity

• Degree of seriousness
• Death
• Injury
• Potential for harm

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Good Faith

• Self-report
• Aware of requirements
• Forthcoming
• Reasonable diligence to comply
• Efforts to correct

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Compliance History

• Repeat Violations
• Violating Orders
• Overdue Forfeitures
• Financial Problems
• Corporate Problems

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Financial Benefit

• Inadequate staffing
• Not investing in training
• Poor food quality
• Inadequate supervision
• Inadequate heat
• Building maintenance
• Telephone
• Transportation

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• Fall from bed with head laceration
• Facility responded with emergency services
• First occurrence
• Fall from bed with head laceration
• Resident remained on floor for 3 hours
• Hospitalized and admitted to nursing home
• History of falling from bed w/o intervention

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• Resident eloped from facility and fell in
  snowbank
• Located within 5 minutes
• First attempt
• Resident eloped from facility and fell in
  snowbank
• Staff unaware until notified by neighbor
• History of wandering
• One caregiver on duty 15 residents CNA

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Department Orders Directed Plans of Correction

• Implement and Comply with a Plan of Correction
  developed by the Dept.
• Objectives
• Constructive resolution to compliance problems
• Combat root causes of violations by directing
  the development and implementation of durable,
  effective systems to improve services and sustain
  compliance

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Dept OrdersGoal

• Within existing regulatory procedures and
  statutes, through collaboration with
  stakeholders, promote the development of
  effective systems (e.g., policies, procedures,
  trained workers, effective care plans) in
  facilities with compliance concerns.

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Types of orders

• Obtain specific training for staff
• Hire a consultant to evaluate and develop systems
• Obtain clinical assessments
• Develop effective service plans
• Develop written procedures

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Directed Plans of Correction

• Expand upon or clarify existing codes and
  licensing requirements
• Stepwise measures to achieve compliance
• Re-invest in facility operation
• Does not replace the facilitys own written plan
  of correction POC must be based on the
  facilitys resident population, staffing
  structures, and existing operation

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Example

• The facility did not investigate injuries of
  unknown origin sustained by residents 1 and 2.
  The injuries were located in areas not generally
  vulnerable to trauma and were suspicious due to
  the location and extent of the injury. Resident
  1 sustained a scalp laceration of unknown origin
  that required emergency room treatment to remove
  a foreign object that was embedded in her scalp.
  Resident 2 was discovered with blood on her face.
  In addition, a family member discovered a bruise
  on resident 2's face that staff could not
  explain. The facility did not complete thorough
  investigations to determine the causes of injury
  and rule out caregiver misconduct.

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Order

• Pursuant to 50.03(5g)(b)6, within 7 days of
  receipt of this notice, copies of the facility's
  reports of investigation into injuries of unknown
  origin sustained by residents 1 and 2, as
  documented in SOD insert current SOD , will
  be submitted to the Office of Caregiver Quality.
  Furthermore, within 30 days of this notice, the
  facility will develop (or revise) and implement a
  detailed, written policy on reporting,
  documenting, and thoroughly investigating
  allegations of caregiver misconduct and injuries
  of unknown origin. The policy will incorporate
  reporting and investigation requirements
  specified by HFS Chapter 13 and BQA memo 04-028
  (enclosed) and will include measures to ensure
  that residents are protected from subsequent
  episodes of misconduct while an investigation is
  pending. All staff will receive inservice
  training regarding the written policy. Employee
  files will contain documentation of training
  including the date/duration of training, the
  signature/qualifications of the instructor, and
  an outline of course content. The facility's
  written policy will be maintained onsite for
  staff reference. Within 30 days of this notice,
  a copy of the policy will be submitted to the
  regional office with the facility's written plan
  of correction.

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What if a facility doesnt comply with a
department order?

• Although circumstances vary, the department
  typically issues a citation for failing to comply
  with orders. Often a forfeiture is assessed and
  may include an accruing forfeiture until
  compliance is achieved.
• Licensee Responsibilities

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Appeals

• AFHs (rule and statute do not include appeal
  rights unless license is revoked)
• CBRFs/RCACs can request an appeal within 10 days
  for any enforcement action, including
• plan of correction
• forfeitures
• orders
• any other sanction

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Survey Results
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Surveys with Enforcement
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Type of Sanctions
2001
2005
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Forfeiture Assessments
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In Summary.

• Subject to Enforcement Review
• Serious
• Repeat
• Target violations
• The Statement of Deficiency basis for
  enforcement decisions
• Statistics
• http//dhfs.wisconsin.gov/bqaconsumer/AssistedLivi
  ng/AstLvgStats.htm

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BQA Assisted Living Section

• Enforcement Review
• Lynnette Traas, CSW, MS
• QA Program Specialist
• traaslm_at_dhfs.state.wi.us
• [phone]