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Assisted Living Forum“State of Assisted Living”
September 9, 2008
New DQA Assisted Living Boundaries – effective 1-1-2007
Where are we going?2008 - 2009
Continue and Expand Collaborations
Using data to effect positive change
Deploying Resources to Effect Positive Change
Proactive Compliance
Implement HFS 83
New facility video on Web
Medication Management Initiative
Make more information available on the web – statistics, trends, etc.
Support and Encourage Innovation
To have the best staff with the tools and training to do their job
Trends & Statistics
Assisted LivingTrend in # of Facilities
0
216
1165
77
675
1348
107
718
1359
152
765
1352
171
834
1367
188
965
1372
203
1049
1382
218
1130
1403
224
1147
1414
0200400600800
10001200
14001600
1995 2001 2002 2003 2004 2005 2006 2007 Jun-08
RCAC AFH CBRF
Assisted LivingTrend in capacity for residents
0838
17771
29662629
21105
40272786
21505
6055
2964
21392
6614
3217
21739
8003
3727
21996
8980
4054
22408
9562
4358
22822
9914
4431
23033
0
5000
10000
15000
20000
25000
1995 2001 2002 2003 2004 2005 2006 2007 Jun-08
RCAC AFH CBRF
RCACs Certified vs. Registered
4455
99
59 55
104
63 60
123
8667
153
9477
171
10484
188
11588
203
125
93
218
129
95
224
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 Jun-08
Certified Registered Total
AL vs. LTCTrend in number of facilities
472 458 451 444 439 436 425 421 415
1448
2100 2184 2269 23722525 2634 2751 2785
0
500
1000
1500
2000
2500
3000
1995 2001 2002 2003 2004 2005 2006 2007 Jun-08
LTC - NH, FDD AL - CBRF, AFH, RCAC
AL vs. LTCTrend in capacity for residents
5262848220 46216
43052 42074 41010 40054 39296
20278
26700 28318 30411 3157033726 35442 36742
3852437378
0
10000
20000
30000
40000
50000
60000
1995 2001 2002 2003 2004 2005 2006 2007 Jun-08
LTC AL
Family Care Impact on AL Industry
Family Care counties
Rest of State
2000 Capacity 4.3 beds/100 3.2 beds/100
2006 Capacity 5.9 beds/100 3.7 beds/100
Average increase
36.3% 21.8%
Projections indicate 62% of the state will be covered by Family Care by June, 2009
Relocations
• 540 of 1412 residents of ICF/MRs have been moved:– 449 moved into BAL regulated facilities
• 341 into 3-4 bed AFHs
• 108 into 5-8 bed CBRFs
– 872 residents are left to be moved
• 1,282 nursing home relocations have been completed (majority to BAL regulated facilities)– 905 elderly residents
– 379 individuals with developmental disabilities
Nursing Home Diversions
• 300 slots
• Majority to BAL regulated facilities
Population Served• 4215 assisted living residents with Long Term Care Functional
Screen data:– 34% have diagnosis of Alzheimer’s disease– 92.6% need assistance with bathing– 70.5% need assistance with dressing– 33.4% need assistance with eating– 49.9% need assistance with toileting– 18.3% require a behavior intervention– 3,460 MH diagnoses (depression, anxiety, bipolor, schizophrenia)– 56.7% use a walker– 26.7% use a wheelchair or scooter
• These residents are publicly funded under MA Waivers, Family Care, or Pace/Partnership to live in AFHs, CBRFs, and RCACs
Waiting Lists
• As of May 31, 2007 – 11,625 on the COP/Waiver waiting list
• With entitlement, how many of these will be living in BAL regulated facilities….?
Publicly Funded Clients in AL* Estimated publicly funded clients in occupied AL beds
28%
44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
2004 2006
Public Funding becoming more influential driver…..
New AL vs. Closed AL
192
307
261 256289276
247223
322
243
352323 321
293
125145
0
50
100
150
200
250
300
350
400
2001 2002 2003 2004 2005 2006 2007 Jun-08
newclosed
Why Facilities ClosedCY 2007
1416
19
107
95
50
VoluntaryCHOWWithdrew App.Location ChangeConversionOtherRevoke/Deny
Why Facilities Closed6 months June 30, 2008
1 4
04
63
49
24VoluntaryCHOWWithdrew App.Location ChangeConversionOtherRevoke/Deny
Post Survey Questionnaire
• 2007 - 161 respondents (37% of total)
• Satisfaction with survey tasks 97.3%
• On Site - 4.57
– Knowledgeable - 4.57
– Professional - 4.76
– Respectful - 4.71
• SOD – 4.21
(1 = strongly disagree, 5 = strongly agree)
Survey Results
15% 62%
23% 2004
61%14%
25%
2006
65%
13%
22%
no citesSOD onlySOD w/ Enfor.
2005
62%15%
23%2007
Survey Results Jan-June 2008
62%16%
22% no citesSOD onlySOD w/ Enfor.
AL Citations Issued 2759
1296
26252421 2569 2592
3.0
3.7
3.33.3 3.3
0
500
1000
1500
2000
2500
3000
CY 2004 CY 2005 CY 2006 CY 2007 Jan-Jun08 Proj 2008
0
0.5
1
1.5
2
2.5
3
3.5
4
Cites Ave per Survey
33
33
33
33
38
39
40
42
50
54
58
58
35
28
41
59
60
35
45
46
44
47
0 10 20 30 40 50 60 70
SAFE ENVIRONMENT
QUARTERLY FIRE DRILLS
SUPERVISION
REVIEW OF PROGRESS
RESPONSIBILITIES
COMMUNICABLE DISEASE CONTROL
MEDICATIONS
TESTING BY SERVICE COMPANY
PROMPT AND ADEQUATE TREATMENT
SLEEPING HOURS EVACUATION DRILL
BUILDING MAINTENANCE
FIRE SAFETY, FIRST AID & CHOKING
INDIVIDUALIZED SERVICE PLAN-SCOPE
2006
2007
Top CBRF cites comparison: 2006-2007
T o p T e n C i t a t io n C B R F s ( J a n - J u n 2 0 0 8 )
3 52 6
2 52 5
1 81 8
1 71 7
1 61 4
R E S P O N S I B I L I T I E S
B U I L D I N G M A I N T E N A N C E
P R O M P T A N D A D E Q U A T E T R E A T M E N T
M E D I C A T I O N S
S L E E P I N G H O U R S E V A C U A T I O N D R I L L
Top Citations RCACs (CY 2007)
0 1 2 3 4 5 6Number of Citations
89.34(16) TENANT RIGHTS89.56(2) PLAN OF CORRECTION89.26(4) ANNUAL REVIEW89.29(2)(b)1 ADMISSION & RETENTION OF TENANTS89.34(1) TENANT RIGHTS89.23(4)(b)1 SERVICES89.23(4)(a)2 SERVICES89.28(1) RISK AGREEMENT
Top Citations (RCAC) Jan-Jun 2008
3
2
1 1 1 1 1 1 1 1 1 1
Tenant Rights 89.34(16)
Services89.23(2)(c)
Top Twelve Citations AFH CY 2006
31
25
24
23
19
19
18
17
16
14
14
14
REVIEW OF ISP
HEALTH SCREENING FOR STAFF
MEDICATION- WRITTEN ORDER
TRAINING-15 HOURS WITHIN 6 MONTHS
TRAINING-8 HOURS ANNUALLY
RESPONSIBILITIES
HOME ENVIRONMENT
FIRE EVACUATION ANNUAL EVALUATION
SEMI-ANNUAL FIRE DRILLS
FREE OF HAZARDS
INDIVIDUAL SERVICE PLAN & ASSESSMENT
ADMISSION-HEALTH EXAM
Top Ten Citations AFH CY 2007
41
31
29
29
28
25
23
23
22
22
MEDICATION- WRITTEN ORDER
TRAINING-15 HOURS WITHIN 6 MONTHS
HOME ENVIRONMENT
FIRE EVACUATION ANNUAL EVALUATION
RESPONSIBILITIES
FIRE SAFETY-FIRE EXTINGUISHERS
TRAINING-8 HOURS ANNUALLY
SMOKE DETECTORS-TESTING ANDMAINTENANCE
SEMI-ANNUAL FIRE DRILLS
HEALTH SCREENING FOR STAFF
Top 11 Citations (AFH) Jan-Jun 2008
2118
1616
15141414
131212
HOME ENVIRONMENT
RESPONSIBILITIES
MEDICATION- WRITTEN ORDER
DIFFICULTY WALKING
FIRE SAFETY-FIRE EXTINGUISHERS
FIRE EVACUATION ANNUAL EVALUATION
PRESCRIPTION MEDICATIONS
SMOKE DETECTORS-TESTING AND MAINTENANCE
INDIVIDUAL SERVICE PLAN & ASSESSMENT
TRAINING-15 HOURS WITHIN 6 MONTHS
SEMI-ANNUAL FIRE DRILLS
Surveys with Enforcement
162
294
373471 447
505
409467
545
245
0
100
200
300
400
500
600
2000 2001 2002 2003 2004 2005 2005-4yr
2006 2007 Jun-08
2.46.7 11.0
15.3
0102030405060708090
100
25% 50% 75% 100%
% of Facilities making up % of Enforcement CY 2007
% of Facilities % of Enforcement
Surveys with Enforcement (545) CY 2007
1
7
397
140
CBRF AFH RCAC ADC
Surveys with Enforcement (241) June 30, 2008
1
4
183
53
CBRF AFH RCAC ADC
% of Facilities vs. % Enforcement Surveys
49
73
40
26
81 3 0
0
10
20
30
40
50
60
70
80
CBRF AFH RCAC ADC
% of Facilities CY 2007 % Enforcement CY 2007
% of Facilities vs. % Enforcement Surveys
49
76
39
22
71
4 10
10
20
30
40
50
60
70
80
CBRF AFH RCAC ADC
% of Facilities June 2008 % Enforcement June 2008
% of Beds vs. % Enforcement Surveys
58
73
11
2624
17
00
10
20
30
40
50
60
70
80
CBRF AFH RCAC ADC
% of Beds CY 2007 % Enforcement CY 2007
% of Beds vs. % Enforcement Surveys
57
76
11
22 25
17
10
10
20
30
40
50
60
70
80
CBRF AFH RCAC ADC
% of Beds June 2008 % Enforcement June 2008
Sanctions Imposed (1,077)CY 2007
1
14
827
235
CBRF AFH RCAC ADC
Sanctions Imposed (486)June 30, 2008
1
5
383
97
CBRF AFH RCAC ADC
Type of SanctionsCY 2007
61
362
49
4
370
216
15Comply POCComply Req.ForfeitureProvide TrainingRevoke/DenyNo AdmissionOther
Type of SanctionsJune 30, 2008
25
160
57
8
147
80
9
Comply POCComply Req.ForfeitureProvide TrainingRevoke/DenyNo AdmissionOther
Top Ten Citations w/Forfeitures CBRF CY 2007
$33,875
$16,850
$15,800
$11,875
$8,800
$8,100
$7,760
$7,400
$6,875
$6,300
PROMPT AND ADEQUATE TREATMENT
SUPERVISION
FIRE SAFETY, FIRST AID & CHOKING
MEDICATIONS
RESPONSIBILITIES
INDIVIDUALIZED SERVICE PLAN-SCOPE
ADEQUATE STAFFING
UNIVERSAL PRECAUTIONS
PREPAID FEES RETURNED WITHIN 10 DAYS
STAFFING PATTERNS
Top Ten Citations w/Forfeiture (CBRF) Jan-Jun 2008
$31,020
$23,570
$17,940
$17,310
$8,900
$8,425
$8,000
$7,300
$6,600
$5,800
RESPONSIBILITIES
PROMPT AND ADEQUATE TREATMENT
MEDICATIONS
ADEQUATE STAFFING
SUPERVISION
CBRF ARRANGE HEALTH VISITS AND DOCUMENT
CLIENT GROUP SPECIFIC SERVICES
SAFE ENVIRONMENT
MEDICATION ERRORS AND ADVERSE REACTIONS
FIRE SAFETY, FIRST AID & CHOKING
Forfeiture Assessments
$88,230$126,102
$314,954
$459,830$407,102
$439,406
$547,300
$433,055
$309,282
$0
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
2000 2001 2002 2003 2004 2005 2006 2007 Jun-08
50
34
44
57
49
57
0
10
20
30
40
50
60
2003 2004 2005 2006 2007 Jun-08
Assisted Living No New Admission Orders
Impending Revocations
5 5
12
16
11
0
2
4
6
8
10
12
14
16
2004 2005 2006 2007 Jun-08
Impending Revocation
Impending Revocations 2007
3
2
1
2
4
1
3
CBRF 3 2 1 0 2
AFH 4 0 0 1 3
Pending Close Vol Revoked Rescinded Corrected
Impending Revocations June 30, 2008
1
0
3
2
1
3
0 0
1
0
CBRF 1 0 3 2 1
AFH 3 0 1 0 0
Pending Close Vol Revoked Rescinded Corrected
Revocations
1
8
19
34
15
108
02468
101214161820
2001 2002 2003 2004 2005 2006 2007 Jun-08
CBRFAFHRCACADCTotal
87
1
2005 2006 2007
Cease & Desist Orders Unlicensed Entity
35% Forfeiture Reduction
0
50
100
150
200
250
300
# Pd Reduction 176 202 213 268 124
Other Pmt 238 92 83 123 41
% choosing 35% 43% 68% 72% 69% 75%
CY 2004 CY 2005 CY 2006 CY 2007Jan-
Jun08
Enforcement Action Appealed
45, 10%
422, 90%
# appealed # not appealed
62, 12%
448, 88%
CY 2005 CY 2006
510, 94%
35, 6%
CY 2007
Enforcement Action Appealed
35, 15%
206, 85%
# appealed # not appealed
6 months, June 30, 2008
Complaints Received
605
916792
667 677 718681
355
0
100
200
300
400
500
600
700
800
900
1000
2001 2002 2003 2004 2005 2006 2007 Jun-08
Complaints vs. Growth
718 681
2197 2284 2370 24772631 2731 2853
677667792916
605
0
500
1000
1500
2000
2500
3000
2001 2002 2003 2004 2005 2006 2007
# complaints # AL Facilities
1.5 4.39.8
15.4
0
1020
3040
5060
7080
90100
25% 50% 75% 100%
% of Facilities making up % of Complaints CY 2007
% of Facilities % of Complaints
Complaints ReceivedCY 2007
2
472
63144 ADC
AFH
CBRF
RCAC
Complaints ReceivedJune 30, 2008
1
239
31
84 ADCAFHCBRFRCAC
% of Facilities vs. Complaints Received
49
69
40
21
8 10
3 00
10
20
30
40
50
60
70
CBRF AFH RCAC ADC
% Facilities CY 2007 % Compl. CY 2007
% of Facilities vs. % Complaints received
49
67
39
23
7 94 1
0
10
20
30
40
50
60
70
CBRF AFH RCAC ADC
% of Facilities June 2008 % Complaints June 2008
% of Beds vs. Complaints Received
58
69
11
2124
107
00
10
20
30
40
50
60
70
CBRF AFH RCAC ADC
% Facilities CY 2007 % Compl. CY 2007
% of Beds vs. % Complaints received
57
67
11
23 25
9 71
0
10
20
30
40
50
60
70
CBRF AFH RCAC ADC
% of Beds June 2008 % Complaints June 2008
Source of ComplaintCY 2007
25%
24%
19%
5%
10%
4%
4%
3% 6%AnonomousPublic OfficalRelative/GuardianCurrent EmployeeFormer EmployeeMedicalCitizenResidentAdvocate
Ranking – Subject areas complaint investigations
2002 2003 2004 2005 2006 2007Program Services
1 2 1 1 4 4Medications
4 5 5 2 3 3Resident Rights 2 4 4 3 1 1Administration
3 1 2 4 2 2Res. Behavior/ Facility practice
8 3 3 5 5 10Nutrition & Food 6 6 7 6 6 8Staff Adequacy
7 9 8 7 7 7Abuse
12 12 11 8 9 5
Source % rec. & invest. % substantiatedAnonymous 23 29Public Official 24 53Relative/Guardian 19 41Current Employee 05 42Former Employee 10 47Advocate 06 51Citizen 05 28Medical 05 34Resident 02 23
100% 41%
Source of Complaint vs SubstantiationCY 2007
Self Reports Received - CY 2007 (1,856)
466
1150
240
Open Investigation Review next visit File
Self Reports Received - June 2008 (991)
319616
56
Open Investigation Review next visit File
Self ReportsCY 2007
776
220142
173
140
8571 24
201
186FallsRes. BehaviorPoliceElopmentHospital (not fall)OtherMisappropriationAbuseNeglectFireComm. Disease
Self Reports Investigated - CY 2007 (1,271)
65
1206
No SOD SOD
Self Reports Investigated - June 2008 (715)
43
672
No SOD SOD
Facilities Qualifying for Abbreviated Surveys – June 2008
• Adult Day Care 61.3%• Adult Family Homes 42.7%• Community Based Residential Facility 38.9%• Residential Care Apartment Complex 50.4%
• Statewide 42.2%
Facilities Qualifying for an Abbreviated Survey
37.20%37.90%
38.20%
40.50%
39.30%
42.20%
34.00%
35.00%
36.00%
37.00%
38.00%
39.00%
40.00%
41.00%
42.00%
43.00%
2003 2004 2005 2006 2007 Jun-08
Stories ….(examples of enforcement actions)
IN SUMMARY….• Growth continues across all Assisted Living providers
although new licenses issued appears to be declining somewhat. More RCAC growth with certified as the gap with registered continues to widen.
• ICF/MR rebalancing, NH relocation initiative and Family Care expansion having direct impact on AL growth. AL licensed beds projected to exceed NH & ICF/MR licensed beds by end of 2008 or early 2009
• In addition to overall growth, there is significant turnover with increases in voluntary closures, and Change of Ownership (CHOW)
• Fit and Qualified policy having a positive effect with increase of license denials and withdrawn applications
IN SUMMARY….• Citations per survey decreased slightly.• Top citations and type of sanctions more reflective of
deployment of resources to facilities with non-compliance concerns or allegations
• BAL continues to refine directed plans of correction to help facilities achieve and sustain compliance. When this does not work, progressive, punitive enforcement usually does
• Compared to number of facilities and beds, CBRFs make up a significantly high proportion of enforcement
• Compared to number of beds, AFHs make up a significantly high proportion of enforcement although it did decrease from CY 2007
IN SUMMARY….
• Complaints projected to increase slightly• Compared to number of facilities and
beds, CBRFs make up a significantly high proportion of complaints
• Compared to number of beds AFHs make up a significantly high proportion of complaints and appears to be increasing
IN SUMMARY….
• Self reports received is projected to increase again, but when investigated rarely result in deficiencies.
• BAL not meeting the workload with overall growth in industry, more complex investigations, increased enforcement and self reports.
IN SUMMARY….
• The “new resident” is impacting the regulatory activity
• Majority of assisted living in Wisconsin is very good and continues to improve
• Collaboration continues to move the “bell curve to the right”
• More facilities qualifying for abbreviated surveys• For CY 2007 only 15 % of facilities make up
100% of the complaints and enforcement action.
Thank You!
Moving the Bell Curve to the Right...
