Consumer Guide: Understanding Assisted Living Facility Profiles

Identifies the name and address of the facility.

License status: regular or probationary. DQA issues all assisted living facilities a regular license, certificate, or registration, except CBRFs. CBRFs are issued a probationary license for the first year of operation.

Licensed, certified, or registered: The date indicates when the facility received its initial license, certification, or registration. Adult family homes and CBRFs are licensed. Adult day care centers are certified. RCACs may be certified or registered.

DQA surveys assisted living facilities about every two years. The survey ensures compliance with Wisconsin administrative codes, statutes, and standards.

Other reviews may take place for complaint investigations, verification visits, or follow up on facility self-reports.

The survey history section of the profile shows all surveys during the reporting period shown at the top of the report.

End date: Date inspection was completed.

Type: Type of survey may be initial, abbreviated, standard, or other.

• Initial: Inspection done before issuing a facility's first license or certification.
• Abbreviated: At DQA's discretion, the abbreviated survey process is used for facilities with a compliance history that meets these criteria:
  • No enforcement activity within the last three years.
  • Must have received a standard survey since initial licensure or certification.
  • No substantiated complaints resulting in deficiencies within the last three years.
  • Facility has been licensed or certified for at least three years.
• Standard: A standard survey process is used for facilities that don't meet the criteria for an abbreviated or initial survey.
• Other: Complaint, self-report, or verification visit.

Purpose: The reason an inspection occurred. These are the possible reasons: a two-year survey, complaint investigation, self-report investigation, a verification visit, or any combination of these.

Results: Action taken by DQA in response to the inspection. The possible results are:

• Issuance of a license or certificate
• No statement of deficiency
• Statement of deficiency
• Enforcement

Statement of deficiency: Used to identify incidents of noncompliance that:

• Result in more than minimal harm, but not serious harm
• Have potential for more than minimal harm, but not serious harm
• Indicate a breakdown in facility systems

On October 1, 2020, the Bureau of Assisted Living began a new policy. The policy no longer regularly requires the provider to submit a traditional plan of correction for violations.

Served: Date licensee receives the statement of deficiency.

Deficiencies cited: Refers to the Wisconsin administrative code, statute, or standard for the incident of noncompliance.

Subject area: Description title of the referenced Wisconsin administrative code, statute, or standard. Compliance verified: Date DQA verifies correction of the noncompliance. If blank, then the noncompliance hasn't been verified.

Compliance verified: Date DQA verifies correction of the noncompliance. If blank, then the noncompliance hasn't been verified.

Corrected: This item lists one of these responses:

• Yes: A verification visit was conducted, and the deficiency was corrected.
• No: A verification visit was conducted, but the deficiency was found to be uncorrected.
• N/A: For isolated incidents of noncompliance, DHS may not conduct a verification visit. This includes incidents that result in no harm, or have potential for no more than minimal harm, or don't indicate a breakdown in facility systems.
• Variance: The facility requested and was issued a variance. This allows the facility a different way to meet the requirement.
• Waiver: The facility requested and was issued a waiver making it exempt from the requirement.
• (Blank/Empty): DQA hasn't completed a verification visit to determine compliance.

This part of the facility profile shows an occurrence from the survey history section that resulted in DQA issuing a sanction against the facility. Deficiencies resulting in enforcement action include those that:

• Result in serious harm, have a potential for serious harm, or indicate a breakdown in facility systems that could lead to serious harm.
• Create a condition or occurrence that presents a substantial probability that death or serious mental or physical harm to a resident will (or did) result.
• Create a condition or occurrence that presents a direct threat to the health, safety, or welfare of a resident.
• Are repeated, uncorrected, or target violations. One example of a target violation is a staff training requirement that results in enforcement action.

SOD #: Number on the statement of deficiency (SOD) that corresponds to the SOD # under survey history

Appeal: Assisted living facilities have a right to dispute inspection findings. They can appeal to the Division of Hearing and Appeals. Appeals may be resolved with stipulated settlement agreements, or they may go to hearing before an administrative law judge.

Decision: Results of the appeal process could be:

• Pending: DHS action has been appealed and is awaiting resolution
• Withdrawn: Petitioner withdraws appeal request prior to hearing
• Upheld: Hearing decision rules in favor of department
• Reversed: Hearing decision rules in favor of petitioner
• Split-decision: Ruling in favor of a portion of the department's action and a portion of the petitioner's appeal

Stipulation: A stipulated settlement agreement between DHS and the petitioner. It resolves original survey findings and enforcement actions without a formal hearing. Examples include a reduced forfeiture, amended language on the SOD, or a withdrawn citation.

Sanction: Under state law (Wis. Stat. ch. 50 and applicable Wisconsin administrative code), DQA has the authority to impose these penalties:

• Forfeiture
• No new admissions
• Revocation
• Orders to comply with corrective action specified by the DQA
• Order to obtain training
• Order to stop violating a provision of licensure

The complaint history section includes all complaints that had a completed investigation during the time period identified at the top of the report. Pending complaints don't appear on this report.

Date complaint received: Date DHS received the letter, telephone call, or email from a complainant

Date investigation completed: Date all aspects of the complaint investigation were concluded

Subject area: Identifies area(s) of concern reported by the complainant

Result:

• Substantiated: A deficient practice was identified related to the complaint, and a statement of deficiency was issued.
• Unsubstantiated: No deficient practice was identified related to the complaint.

SOD #: An SOD is issued if the subject area of a complaint is substantiated. See the survey history and enforcement history sections above for more details about the SOD.