state of assisted living mid year 2016 november 8, 2016 · p-01726 (12/2016) promoting regulatory...
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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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Quality Assurance Program Specialists, Senior
• Lynnette Traas
• Cindy O’Connell
• Vacant, Enforcement Specialist
Bureau of Assisted Living Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Central Office Staff
• Colette Anderson, Research Technician
• Damon Scott, Office Operations Program Associate
• Lori Smithback, Central Licensing Associate
• Chquota Carter, Central Health Service Specialist
Bureau of Assisted Living Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
Bureau of Assisted Living Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
Bureau of Assisted Living Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Surveyors
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
Bureau of Assisted Living Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living Staffing
Assisted Living Surveyors
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Surveyors
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 Staffing
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Assisted Living Facilities
•Wis. Admin. Code ch. DHS 88
•Wis. Stat. ch. 50
•Wis. Admin. Code ch. DHS 89
•Wis. Stat. ch. 50
•Wis. Admin. Code ch. DHS 83
•Wis. Stat. ch. 50
•Adult Day Standards
Adult day care
Community-based
residential facility
Adult family home
Residential care
apartment complexes
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Regulatory Trends
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
Trend in Number of Facilities
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
Trend in Number of Facilities
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Complaints Mid Year 2016
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Complaints Received Mid Year 2016
2%
23%
66%
9%
Complaints ADC AFH CBRF RCAC
P-01726 (12/2016)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Percentage of Facilities with Complaints Submitted
9.9%
90.1%
% of Facilities withComplaints Submitted% of Facilities with NoComplaints
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Source of Complaint Mid Year 2016
44%
11%
25%
2% 3%
3% 4% 5% 3%
AnonymousPublic OfficialRelative or GuardianCurrent EmployeeFormer EmployeeMedicalCitizenResidentAdvocate
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Self-Reports Mid Year 2016
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Self-Reports Received Mid Year 2016 (1,766)
16% 0%
84%
Self-Reports Open Investigation Review Next Visit File
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
99%
1%
Self-Reports Investigated Mid Year 2016 (475)
No SOD SOD
(SOD = Statement of Deficiency)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Abbreviated Surveys Mid Year 2016
• No deficiency survey - 59%
• Statement of deficiency - 41%
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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%
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Enforcement Mid Year 2016
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Percentage of Facilities Receiving Enforcements Mid Year 2016
5.7%
94.3%
% FacilitiesReceivingEnforcement% Facilities WithNo Enforcements
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Assisted Living Surveys with Citations with Appeals Mid Year
2016
98%
2%
Surveys With CitationsAppeals
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Bureau of Assisted Living Strategies
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Coalition for Collaborative Excellence in Assisted
Living (WCCEAL)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Wisconsin Coalition for Collaborative Excellence in
Assisted Living
• Provider association sponsored
• Department approved
• Comprehensive quality assurance (QA) and quality improvement (QI)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Internal Quality Assurance
• Essential to maintain quality!
• Structure, process, and outcome measures used to evaluate quality
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Regulatory Data Mid Year 2016
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Members Complaints Mid Year 2016
Total Facilities 393Total Complaints 81Facilities With Complaints 54
050
100150200250300350400450
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
WCCEAL Regulated Facilities Qualifying for Abbreviated Surveys
Mid Year 2016
Total Number of Facilities 393Qualifying Facilities 231RCAC 80CBRF 124AFH 27
050
100150200250300350400450
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
Life is like a camera, focus on what’s important and you will capture it perfectly. (author unknown)
P-01726 (12/2016) Promoting Regulatory Compliance Division of Quality Assurance
Wisconsin Department of Health Services
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