Assisted Living: Survey Guide

DQA uses seven types of surveys. These surveys involve:

• Interviews with staff and residents.
• Observations of staff and residents.
• Reviews of facility records.

1. Initial and/or Technology-Based - Used to review structural requirements, such as building construction and design and if a building is safe and accessible. The survey also reviews process requirements. Example process requirements include staff training.

   Initial surveys are used when facilities apply for licenses and certifications. Facilities qualify for a technology-based initial survey if they:

   • Have been licensed or certified by DQA in the past.
   • Have a good compliance history of following rules and regulations.

2. Abbreviated - Used for facilities in good standing who meet the following:

   • No enforcement activity in the last three years
   • Received a standard survey since receiving a license or certification
   • No substantiated complaints leading to deficiencies within the last three years
   • Licensed or certified for at least three years

   Abbreviated surveys use observations and interviews to make sure the needs of residents are being met.

3. Standard - Used when a facility doesn't qualify for an abbreviated or initial survey. Observation and interview techniques are primarily used to gather data during the on-site visit. Review of consumers' records and facility records are done as needed to further investigate concerns identified by observation and interview findings and to determine compliance with process requirements.
4. Complaint - Used to review complaints made against a facility. This includes violations of Wisconsin and/or HCBS rules.
5. Verification - Used make sure a facility has addressed a violation.
6. Self-Report - Used when the Bureau of Assisted Living investigates a self-reported claim.
7. Monitoring - Used when there are concerns about the health, safety, and well-being of residents.

Regional supervisory discretion may address individual cases where an exception may be made to the identified survey type.

There are three survey processes: Initial, Standard, and Abbreviated.

Initial survey process

Initial surveys are used when facilities apply for licenses and certifications.

All license and certificate applications are reviewed to make sure a facility:

• Is qualified for a license or certificate.
• Meets financial stability requirements.
• Is ready for an on-site visit.

During an on-site visit, a surveyor may review:

• The design and construction of the facility.
• If the building is safe and accessible.

Surveyors also review if process requirements are being followed. If needed, a surveyor provides technical assistance.

Important: Required materials must be submitted before an on-site survey.

Abbreviated survey process

An abbreviated survey process is less involved than the standard process. It consists of the following steps:

1. Off-site review - Surveyors review a facility's history. This includes their history of following regulations, facility client group served, any changes since the last survey, and any areas of concern. A surveyor also decides which survey will be used.
2. Meeting with staff in charge - This step introduces surveyors to staff at a facility. The surveyor can also explain the survey process. The surveyor provides:
   • A link to the Survey Guide.
   • A list of documents needed for review during the survey process.
   • Post-survey questionnaire.
3. Tour - During this step, the surveyor tours the facility with available staff. During the tour, the surveyor will talk with staff and residents. This helps a surveyor learn about the facility and level of services provided. It also helps them learn about residents' perception of the services received.
4. Observations - This task involves close observations of residents. Surveyors will watch for the following:
   • Does a facility promote and protect resident rights?
   • Are resident needs and preferences being met?
   • Does the facility provide a homelike environment and physical safety?
5. Interviews - Surveyors meet privately with residents, family members/representatives, and staff. Interviews help clarify information gathered during observations.
6. Record review - Surveyors gather and review resident and personnel documents. They check to make sure a facility is following all rules. Example records include proof of staff training.
7. Safety code review - This task looks at several safety factors. It may include a review of:
   • Fire safety.
   • Evacuation.
   • Storage of hazardous materials.
   • Required inspections.

8. Assistance - A surveyor can help assisted living facilities in different ways. This assistance can help promote the quality of life for residents.

   Assistance includes:

   • Technical assistance.
   • Standards of practice review.
   • Facility quality improvement.

   Technical assistance may include:

   • Understanding license or certificate requirements.
   • Guidance related to resident quality of life and care.
   • Review of provider systems, processes, and policies within the context of regulatory requirements.
   • Sharing information about:
     • Non-core code issues.
     • New programs that can improve resident quality of life.
     • Resources.

   Note: Facilities are still responsible for following rules and regulations.

   Standards of practice are standards used across the nation. A surveyor may help facilities follow standards of practice by:

   • Providing information and resources.
   • Showing how standards of practice improve residents' quality of life.
   • Recognizing the successful use of standards of practice.

   Facility quality improvement involves:

   • Collecting and analyzing data.
   • Detecting/responding to violations.
   • Reviewing assisted living facility processes and policies.

9. Exit Conference - During an exit conference, a surveyor discusses survey findings with facility leaders. The general objective of this meeting is to explain the preliminary findings and areas of concern.

   Note: The Bureau of Assisted Living no longer requires a Plan of Correction be submitted to the bureau on a regular basis. Instead, facilities should have an internal way to:

   • Make sure all rules and regulations are being followed.
   • Detect and correct violations when they happen.
   • Collect and review data related to facility activities.
   • Assess assisted living facility processes policies.

Standard survey process

Some facilities don't qualify for abbreviated or initial surveys. In these cases, standard survey processes are used.

The standard survey process consists of the following steps:

1. Off-site review - Surveyors review a facility's history. This includes its history of following regulations, facility client group served, any changes since the last survey, and any areas of concern. A surveyor also decides which survey will be used.
2. Meeting with staff in charge - This step introduces surveyors to staff at a facility. The surveyor can also explain the survey process. The surveyor provides:
   • A link to the Survey Guide.
   • A list of documents needed for review during the survey process.
   • Post-survey questionnaire.
3. Tour - The surveyor tours the facility with available staff. During the tour, the surveyor talks with staff and residents. This helps a surveyor learn about the facility and level of services provided. It also helps them learn about residents' perception of the services received.
4. Sample selection - A surveyor will select a group of residents to observe.
5. Observations - Surveyors will observe the group of residents for the following:
   • Does a facility promote and protect resident's rights?
   • Are resident needs and choices being met?
   • Does the facility provide a homelike environment and physical safety?
6. Interviews - Surveyors meet privately with residents, family members/representatives, and staff. Interviews help clarify information gathered during observations.
7. Record review - Surveyors gather and review resident and personnel documents. Example records include proof of staff training.
8. Safety code review - This task looks at several environmental safety factors. It may include a review of:
   • Fire safety.
   • Evacuation rules.
   • Storage of hazardous materials.
   • Required inspections.

9. Assistance - A surveyor can help assisted living facilities in different ways. This assistance can help improve the quality of life for residents.

   Assistance includes:

   • Technical assistance.
   • Standards of practice review.
   • Facility quality improvement.

   Technical assistance may include:

   • Understanding license or certificate requirements.
   • Guidance related to resident quality of life and care.
   • Review of provider systems, processes, and policies within the context of regulatory requirements.
   • Sharing information about:
     • Non-core code issues.
     • New programs that can improve resident quality of life.
     • Resources.

   Note: Facilities are still responsible for following all regulations.

   Standards of practice are standards used across the nation. A surveyor may help facilities follow standards of practice by:

   • Providing information and resources.
   • Showing how standards of practice improve residents' quality of life.
   • Recognizing the successful use of standards of practice.

   Facility quality improvement involves:

   • Collecting and reviewing data.
   • Detecting/responding to violations.
   • Reviewing assisted living facility processes and policies.

10. Exit Conference - During an exit conference, a surveyor discusses survey findings with facility leaders. The general objective of this meeting is to explain the preliminary findings and areas of concern.

    Note: The Bureau of Assisted Living no longer requires a Plan of Correction be submitted to the bureau on a regular basis. Instead, facilities should have an internal way to:

    • Make sure all rules and regulations are being followed.
    • Detect and correct violations when they happen.
    • Collect and review data related to facility activities.
    • Assess assisted living facility processes and policies.

A surveyor and their supervisor review survey results. If they found a violation, they will issue a citation. They also decide whether to submit the citation for enforcement review.

Statements of deficiency

A statement of deficiency (SOD) is a legal record. It states that a facility is not following rules and regulations. Surveyors issue these statements after a survey.

Survey results could be documented as one or a combination of the following:

• No Deficiencies: No state violations were identified and issued.
• Statement of Deficiency: Used to identify incidents of noncompliance that:
  • Result in more than minimal, but not serious harm.
  • Have potential for more than minimal harm, but not serious harm.
  • Indicate a breakdown in facility systems.
• Statement of Deficiency with Enforcement: Used to identify incidents of noncompliance that:
  • Result in serious harm.
  • Have potential for serious harm.
  • Indicate a breakdown in facility systems that could lead to serious harm.
  • Meet the criteria identified in the Enforcement Guidelines.

Results are sent by mail or email after the exit conference. Some results contain no new admission orders, no new admission order extended, or revocation. A courtesy copy of these results also will be sent to:

• The county.
• Waiver agencies.
• The Division of Medicaid Services.
• Disability Rights Wisconsin.
• The ombudsman.

All other results are uploaded to provider search. Information is also posted on the monthly additions report.

The Wisconsin Department of Health Services (DHS) and DQA use sanctions and penalties to enforce rules and regulations (Wisconsin State Statute Chapter 50; Wisconsin Administrative Codes). These sanctions or penalties are typically categorized as "enforcement."

The enforcement review begins with a statement of deficiency (SOD). The SOD is the written report that follows a compliance survey or investigation wherein the surveyor documents facts that show regulatory noncompliance. The SOD is a legal record of the surveyor's findings and forms the basis for enforcement determination.

When writing a statement of deficiency, surveyors should:

• Document if the violation has happened before (repeat violation).
• Verify that the correct regulation has been selected for the deficient practice identified.
• Describe the violation in clear terms.
• Include specific dates of the violation.
  • Note: Forfeitures are assessed per date of violation.
• Provide detail and sources to support findings. This includes observations, interviews, or records review.
• Describe the effects and consequences of the violation. This can include potential harm.
• Record facts, not opinions.
• Answer:
  • Who was involved?
  • What did or did not happen? How did it happen?
  • What did staff do/not do that led to the violation?
  • When (date/time) did the violation happen?
  • Where did the violation happen?
  • What evidence is used to prove the violation?
• Identify resident and staff by identifies. Staff are identified by title (such as Licensee A).

Violations reviewed for enforcement

Assisted living regional directors send violations to the enforcement specialists. The enforcement specialists impose sanctions and penalties. Violations referred to enforcement specialists include violations that:

• Result in serious harm or have a potential for serious harm.
• Show that facility processes are not working, leading to harm.
• Increase the chances of serious mental/physical harm or death of a resident.
• Pose a threat to the health, safety, and welfare of a resident.

Violations also may be sent to an enforcement specialist for:

• Not meeting minimum staff training requirements.
• Failure to create a safe environment.
• Failure to promote fire safety. This includes failure to meet requirements for:
  • Smoke and heat detection systems.
  • Resident evacuation assessments.
  • Emergency plans and drills.
  • Safe building construction.
  • Inspection or service requirements.
  • Hot water temperatures.
• Abuse or neglect.
• Misappropriation of property.
• Failure to protect resident rights.
• Criminal record checks (repeat violations or serious concerns).
• Failure to provide timely treatment or physician notification causing harm to residents. Examples include:
  • Pressure sores without proper treatment.
  • Falls without intervention.
  • Pain that is not managed.
  • Significant, unplanned weight loss.
  • Illnesses and infections that do not receive medical attention.
  • Preventable injuries.
• Inadequate staffing that puts resident health and safety at risk.
• Lack of supervision.
• Incorrect medication administration
• Insufficient or improper activities.
• Lack of cleanliness or infection control, such as foodborne illness.
• Poor financial management. For example:
  • Unpaid utility bills.
  • Unpaid staff.
  • Not enough groceries and supplies to meet resident needs.
• Repeat violations.

Enforcement action decision-making

Enforcement specialists within the Bureau of Assisted Living reviews violations. They then decide what action to take. This includes which penalties to impose (based on Wisconsin law).

In severe cases, revoking a license may be necessary. The enforcement specialist consults with the following before revoking a license:

• Assisted Living regional director
• Bureau of Assisted Living director/deputy director

The following factors help decide what action to take when addressing violations:

1. The seriousness of a violation. This includes whether the violation will, or has, caused harm.
2. Whether the licensee acted in "good faith." Good faith can include:
   • Being aware of rules and regulations.
   • Making honest efforts to follow rules and regulations.
   • Making efforts to correct violations.
   • Whether a facility self-reports a violation.
3. Any repeat violations.
4. If a facility benefits financially by committing a violation.
5. What penalties have been used for similar violations.
6. How a rule or regulation was violated. Examples include:
   • The number of residents affected by the violation.
   • How bad the potential outcome of the violation is.
   • When or how long the violation occurred.
   • Number of locations in which a violation occurred.

No two violations are the same. That's why enforcement determinations for violations may differ. The enforcement determination and forfeiture amounts, if any, are based on the facts reported in the statement of deficiency.

• Adult family homes, community-based residential facilities - The Bureau of Assisted Living no longer require a "plan of correction" be submitted to the bureau on a regular basis. Assisted living facilities have 45 days to correct violations internally. The Bureau of Assisted Living may conduct a survey after 45 days.
• Certified residential care apartment complexes - These facilities will have 45 days to correct violations after receiving notice. The facility will submit a plan of correction using the Attestation of Correction form, F-02172. The Bureau of Assisted Living may conduct a verification survey after 45 days.
• Registered residential care apartment complexes - When violations are identified, the facility is notified. They are sent a letter showing they are violating a regulation. The facility is to correct violations internally.

The Bureau of Assisted Living may confirm violations have been addressed after 45 days, or sooner if needed.

If DHS investigates a violation, they may conduct an on-site inspection to review the facility's action to correct the violations. This can result in a $200 revisit fee in the following situations:

• Enforcement action against a facility for a chapter 50 violation (Wis. Stat. §§ 50.03(5g)(cm), 50.02(2)(am)2., and 50.034(10)), or rules promulgated under it.

Facilities will be told when revisit fees are due. If revisit fees are not paid in a timely manner, DHS can take further enforcement action. This could include another statement of deficiency.

Failure to correct a violation could result in additional sanctions. Sanctions may include:

• Paying a forfeiture or increased forfeiture.
• Being unable to admit new residents.
• Having a plan of correction created by DHS.
• Losing a license or having it suspended.

Unless you file an appeal, facilities must pay forfeitures within 10 days of receipt of a Notice and Order letter. Forfeitures are payable to "DHS 639."

A facility may appeal the imposition of a statutory sanction, revocation, or denial of licensure if allowed by law.

• Adult family homes
  • Cannot appeal sanctions under Wis. Admin. Code § DHS 88.03(6)(g).
  • Can appeal license denials, revocations, or suspensions (Wis. Stat. § 50.033(4) and Wis. Admin. Code §§ DHS 88.03(3), DHS 88.03(6)(d), and DHS 88.03(6)(e)).
• Community-based residential facilities
  • Can appeal any sanction and penalty under Wis. Stat. § 50.03(5g).
• Certified residential care apartment complexes
  • Can appeal any sanction and penalty under Wis. Stat. § 50.034 and Wis. Admin. Code §§ DHS 89.53(2)(c), DHS 89.53(2)(d), DHS 89.53(4)(b), DHS 89.56, and DHS 89.57.
• Home and community-based services
  • Providers cannot appeal violations related to home and community-based services requirements.

Facilities receive instructions for appealing sanctions and penalties. These are included in a Notice and Order letter that accompany a Statement of Deficiency.

Definitions

• Waiver - The granting of an exemption from a requirement of Wisconsin administrative code.
• Approval - DHS must review practices before a facility can implement them.
• Variance - Facilities can meet regulations in different ways.
• Exception - Granting the omission of a requirement of Wisconsin administrative code.

Submitting a WAVE request

1. WAVE requests may be submitted at any time. The request must be submitted in writing to your assisted living regional director.

   The request should include:

   • The rule for which you are requesting a WAVE.
   • The time period for which the WAVE is requested.
   • The reason for the request.
   • Other ways you plan to meet a legal requirement (variances).
   • WAVEs: which residents or rooms are affected.
   • Proof that resident health or safety will not be negatively affected.

   Please see Waivers, Approvals, Variances, and Exceptions: Assisted Living for instruction on completing a WAVE request.

2. DHS can grant or deny a request. Resident safety and health are priorities when granting a WAVE request.
3. DHS may change a WAVE request, impose conditions on a WAVE request, or limit the time period of a WAVE request.

Revoking a WAVE

DHS may revoke a previously approved WAVE if:

1. A WAVE negatively effects residents.
2. Facilities are not following the conditions of a WAVE.
3. Changes in state or federal law require a change to a WAVE.
4. The facility tells DHS they no longer need a WAVE. This must be submitted in writing.