Assisted Living Section "State of the State"

Assisted Living Section "State of the State"

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 Living Trend in # of Facilities 1600 1400 1200 1000 800 600 400 200 0 1348 1352 1359 1367

1372 1382 1165 965 675 216 0 77 718 107 765 152 1049 1403 1414

1130 1147 218 224 834 171 188 203 1995 2001 2002 2003 2004 2005 2006 2007 Jun08 RCAC AFH CBRF Assisted Living Trend in capacity for residents 25000 21105

20000 21505 21392 21739 22822 21996 22408 23033 17771 15000 10000 6055 5000 0 8980 8003

0 838 4027 2966 2629 2786 9562 9914 6614 2964 3217 3727 4054 4358 4431 1995 2001 2002 2003 2004 2005 2006 2007 Jun08

RCAC AFH CBRF RCACs Certified vs. Registered 250 200 171 153 150 99 100 50 0 44 104 86

63 60 55 59 55 94 67 125 115 104 77 203 188 123 84 218 88 93 224

129 95 2000 2001 2002 2003 2004 2005 2006 2007 Jun08 Certified Registered Total AL vs. LTC Trend in number of facilities 3000 2500 2000 1500 2100 2184 2269 2372 458

451 444 439 2525 2634 2751 2785 436 425 421 415 1448 1000 500

472 0 1995 2001 2002 2003 LTC - NH, FDD 2004 2005 2006 2007 AL - CBRF, AFH, RCAC Jun-08 AL vs. LTC

Trend in capacity for residents 60000 50000 52628 48220 46216 40000 30000 20000 26700 28318 43052 42074 30411 31570 41010

33726 40054 35442 39296 38524 36742 37378 20278 10000 0 1995 2001 2002 2003 2004 LTC 2005 AL 2006

2007 Jun-08 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 36.3% 21.8%

Average increase 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 Alzheimers 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 45% 40% 35% 44% 30% 25% 20% 28% 15% 10% 5% 0% 2004 2006 Public Funding becoming more influential driver..

New AL vs. Closed AL 400 350 307 300 261 256 250 352 322 289276 247 223 323 321 293 243

200 192 150 125 145 100 50 0 2001 2002 2003 2004 2005 2006 2007 Jun-08

new closed Why Facilities Closed CY 2007 1 14 16 9 107 50 95 Voluntary CHOW Withdrew App. Location Change Conversion Other Revoke/Deny

Why Facilities Closed 6 months June 30, 2008 1 0 4 4 24 63 49 Voluntary CHOW Withdrew App. Location Change Conversion Other Revoke/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 2004 23% 15% 22% 25% 62% 13% 23% 15% 65%

61% 14% 2006 no cites SOD only SOD w/ Enfor. 2005 2007 62% Survey Results Jan-June 2008 no cites SOD only SOD w/ Enfor. 22% 16% 62%

AL Citations Issued 3000 2421 2500 3.3 2625 3.7 2569 4 2759 2592 3.3 3.3 3.0

3.5 3 2000 2.5 1296 1500 2 1.5 1000 1 500 0.5 0 0 CY 2004 CY 2005

CY 2006 Cites CY 2007 Jan-Jun08 Ave per Survey Proj 2008 Top CBRF cites comparison: 2006-2007 47 INDIVIDUALIZED SERVICE PLAN-SCOPE 58 FIRE SAFETY, FIRST AID & CHOKING 58 44 BUILDING MAINTENANCE 46

SLEEPING HOURS EVACUATION DRILL 54 50 45 42 PROMPT AND ADEQUATE TREATMENT 35 TESTING BY SERVICE COMPANY MEDICATIONS 40 2006 2007 39 COMMUNICABLE DISEASE CONTROL 60 38

RESPONSIBILITIES 33 REVIEW OF PROGRESS 33 28 SUPERVISION QUARTERLY FIRE DRILLS 59 41 33 33 35 SAFE ENVIRONMENT 0 10 20

30 40 50 60 70 T o p T e n C it a t io n C B R F s ( J a n - J u n 2008) R E S P O N S IB IL IT IE S B U IL D IN G M A IN T E N A N C E P R OM P T A N D A D EQU A TE TR EA TM EN T M E D IC A T IO N S S L E E P IN G H O U R S E V A C U A T IO N D R IL L 14 18 18

17 17 16 26 25 25 35 Top Citations RCACs (CY 2007) 0 1 2 3 4 5 Number of Citations 89.34(16)

89.56(2) 89.26(4) 89.29(2)(b)1 89.34(1) 89.23(4)(b)1 89.23(4)(a)2 89.28(1) TENANT RIGHTS PLAN OF CORRECTION ANNUAL REVIEW ADMISSION & RETENTION OF TENANTS TENANT RIGHTS SERVICES SERVICES RISK AGREEMENT 6 Top Citations (RCAC) Jan-Jun 2008 3 2 1 Tenant Services Rights 89.23(2)(c)

89.34(16) 1 1 1 1 1 1 1 1 1 Top Ten Citations AFH CY 2007 MEDICATION - WRITTEN ORDER 41 TRAINING-15 HOURS WITHIN 6 MONTHS

31 HOME ENVIRONMENT 29 FIRE EVACUATION ANNUAL EVALUATION 29 RESPONSIBILITIES 28 FIRE SAFETY-FIRE EXTINGUISHERS 25 TRAINING-8 HOURS ANNUALLY 23 SMOKE DETECTORS-TESTING AND MAINTENANCE 23

SEMI-ANNUAL FIRE DRILLS 22 HEALTH SCREENING FOR STAFF 22 Top Twelve Citations AFH CY 2006 ADMISSION-HEALTH EXAM 14 INDIVIDUAL SERVICE PLAN & ASSESSMENT 14 FREE OF HAZARDS 14 SEMI-ANNUAL FIRE DRILLS FIRE EVACUATION ANNUAL EVALUATION HOME ENVIRONMENT 16 17

18 RESPONSIBILITIES 19 TRAINING-8 HOURS ANNUALLY 19 TRAINING-15 HOURS WITHIN 6 MONTHS MEDICATION- WRITTEN ORDER HEALTH SCREENING FOR STAFF REVIEW OF ISP 23 24 25 31 Top 11 Citations (AFH) Jan-Jun 2008 21 HOME ENVIRONMENT 18

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 16 16 15 14 14 14 13 12 12 Surveys with Enforcement 600 471 500 373

400 505 447 409 467 294 300 200 545 245 162 100 0 2000 2001 2002 2003 2004 2005 2005- 2006 2007 Jun4yr 08 % of Facilities making up % of Enforcement

CY 2007 100 90 80 70 60 50 40 30 20 10 0 2.4 25% 6.7 50% % of Facilities 11.0 75% % of Enforcement 15.3 100%

Surveys with Enforcement (545) CY 2007 1 7 140 397 CBRF AFH RCAC ADC Surveys with Enforcement (241) June 30, 2008 1 4 53 183

CBRF AFH RCAC ADC % of Facilities vs. % Enforcement Surveys 80 73 70 60 50 49 40 40 26 30 20

8 10 0 1 CBRF AFH % of Facilities CY 2007 RCAC 3 ADC % Enforcement CY 2007 0 % of Facilities vs. % Enforcement Surveys 76 80 70 60

50 49 39 40 30 22 20 7 10 0 1 CBRF AFH % of Facilities June 2008 RCAC 4 ADC

% Enforcement June 2008 1 % of Beds vs. % Enforcement Surveys 80 73 70 60 58 50 40 26 30 20 11 10 0

24 7 1 CBRF AFH % of Beds CY 2007 RCAC ADC % Enforcement CY 2007 0 % of Beds vs. % Enforcement Surveys 76 80 70 60 57

50 40 30 22 20 11 10 0 25 7 1 CBRF AFH % of Beds June 2008 RCAC ADC

% Enforcement June 2008 1 Sanctions Imposed (1,077) CY 2007 1 14 235 827 CBRF AFH RCAC ADC Sanctions Imposed (486) June 30, 2008 1 5 97 383

CBRF AFH RCAC ADC Type of Sanctions CY 2007 4 15 61 49 370 362 216 Comply POC Comply Req. Forfeiture Provide Training

Revoke/Deny No Admission Other Type of Sanctions June 30, 2008 8 9 57 147 25 160 80 Comply POC Comply Req. Forfeiture Provide Training Revoke/Deny No Admission Other Top Ten Citations w/Forfeitures CBRF CY 2007 $33,875

PROMPT AND ADEQUATE TREATMENT $16,850 SUPERVISION $15,800 FIRE SAFETY, FIRST AID & CHOKING $11,875 MEDICATIONS RESPONSIBILITIES $8,800 INDIVIDUALIZED SERVICE PLAN-SCOPE $8,100 ADEQUATE STAFFING $7,760 UNIVERSAL PRECAUTIONS

$7,400 PREPAID FEES RETURNED WITHIN 10 DAYS STAFFING PATTERNS $6,875 $6,300 Top Ten Citations w/Forfeiture (CBRF) Jan-Jun 2008 $31,020 RES P ONS IB ILITIES P ROMP T AND ADEQUATE TREATMENT $23,570 $17,940 MEDIC ATIONS ADEQUATE S TAFFING S UP ERVIS ION C BRF ARRANGE HEALTH VIS ITS AND DOC UMENT C LIENT GROUP S P EC IFIC S ERVIC ES S AFE ENVIRONMENT MEDIC ATION ERRORS AND ADVERS E REAC TIONS

FIRE S AFETY, FIRS T AID & C HOKING $17,310 $8,900 $8,425 $8,000 $7,300 $6,600 $5,800 Forfeiture Assessments $600,000 $547,300 $459,830 $439,406 $407,102 $500,000 $400,000 $433,055 $314,954

$309,282 $300,000 $200,000 $126,102 $88,230 $100,000 $0 2000 2001 2002 2003 2004 2005 2006 2007

Jun-08 Assisted Living No New Admission Orders 60 57 50 40 50 30 57 49 44 34 20 10 0 2003 2004

2005 2006 2007 Jun-08 Impending Revocations 16 14 16 12 10 12 11 8 6 4 5 5

2004 2005 2 0 2006 Impending Revocation 2007 Jun-08 Impending Revocations 2007 4 3 3 2 2 1 1

Pending Close Vol Revoked Rescinded Corrected CBRF AFH 3 4 2 0 1 0 0 1 2 3 Impending Revocations June 30, 2008 3 3 2 1

1 0 1 0 0 0 Pending Close Vol Revoked Rescinded Corrected CBRF AFH 1 3 0 0 3 1 2 0

1 0 Revocations 20 18 16 14 12 10 8 6 4 2 0 19 15 10 8 3 8 4

1 2001 2002 2003 2004 2005 2006 2007 Jun08 CBRF AFH RCAC ADC Total 8 Cease & Desist Orders Unlicensed Entity 7 1 2005 2006 2007 35% Forfeiture Reduction 300 250 200

150 100 50 0 CY 2004 CY 2005 CY 2006 CY 2007 JanJun08 # Pd Reduction 176 202 213 268 124 Other Pmt 238 92 83

123 41 % choosing 35% 43% 68% 72% 69% 75% Enforcement Action Appealed CY 2005 62, 12% 448, 88% CY 2006

45, 10% 422, 90% # appealed CY 2007 35, 6% 510, 94% # not appealed Enforcement Action Appealed 6 months, June 30, 2008 35, 15% 206, 85% # appealed # not appealed

Complaints Received 1000 900 800 700 600 500 400 300 200 100 0 916 792 667 605 677 718 681 355

2001 2002 2003 2004 2005 2006 2007 Jun-08 Complaints vs. Growth 3000 2500 2000 2197 2284 2370

916 792 2477 2631 2731 2853 677 718 681 1500 1000 605 667 500 0

2001 2002 2003 2004 # complaints 2005 2006 # AL Facilities 2007 % of Facilities making up % of Complaints CY 2007 100 90 80 70 60 50 40

30 20 10 0 1.5 25% 4.3 50% % of Facilities 9.8 75% % of Complaints 15.4 100% Complaints Received CY 2007 2 63 144 472

ADC AFH CBRF RCAC Complaints Received June 30, 2008 1 31 84 239 ADC AFH CBRF RCAC % of Facilities vs. Complaints Received 69 70 60 50 49

40 40 30 21 20 8 10 0 10 3 CBRF AFH % Facilities CY 2007 RCAC % Compl. CY 2007 ADC

0 % of Facilities vs. % Complaints received 67 70 60 50 49 39 40 30 23 20 7 10 0 CBRF AFH

% of Facilities June 2008 9 RCAC 4 ADC % Complaints June 2008 1 % of Beds vs. Complaints Received 69 70 60 58 50 40 30 21

20 11 10 0 24 10 7 0 CBRF AFH % Facilities CY 2007 RCAC % Compl. CY 2007 ADC % of Beds vs. % Complaints received 67

70 60 57 50 40 30 23 20 11 10 0 CBRF AFH % of Beds June 2008 25 9

RCAC 7 ADC % Complaints June 2008 1 Source of Complaint CY 2007 3% 6% 4% 25% 4% 10% 5% 24% 19% Anonomous Public Offical Relative/Guardian Current Employee Former Employee

Medical Citizen Resident Advocate Ranking Subject areas complaint investigations 2002 2003 2004 2005 2006 2007 Program Services 1 2 1 1

4 4 Medications 4 5 5 2 3 3 Resident Rights 2 4 4

3 1 1 Administration 3 1 2 4 2 2 Res. Behavior/ Facility practice 8

3 3 5 5 10 Nutrition & Food 6 6 7 6 6 8 Staff Adequacy

7 9 8 7 7 7 12 12 11 8 9 5 Abuse Source of Complaint vs Substantiation

CY 2007 Source % rec. & invest. Anonymous 23 Public Official 24 Relative/Guardian 19 Current Employee 05 Former Employee 10 Advocate 06 Citizen 05 Medical 05 Resident 02 100% % substantiated 29 53 41

42 47 51 28 34 23 41% Self Reports Received - CY 2007 (1,856) 1150 466 240 Open Investigation Review next visit File Self Reports Received - June 2008 (991) 616 319 56

Open Investigation Review next visit File Self Reports CY 2007 18 71 24 6 85 201 776 140 173 142 220 Falls Res. Behavior Police Elopment Hospital (not fall) Other Misappropriation

Abuse Neglect Fire Comm. Disease Self Reports Investigated - CY 2007 (1,271) 1206 65 No SOD SOD Self Reports Investigated - June 2008 (715) 672 43 No SOD SOD Facilities Qualifying for Abbreviated Surveys June 2008 Adult Day Care

Adult Family Homes Community Based Residential Facility Residential Care Apartment Complex Statewide 61.3% 42.7% 38.9% 50.4% 42.2% Facilities Qualifying for an Abbreviated Survey 43.00% 42.20% 42.00% 40.50% 41.00% 40.00% 39.00% 38.00% 37.90%

39.30% 38.20% 37.20% 37.00% 36.00% 35.00% 34.00% 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. Moving the Bell Curve to the Right... Thank You!

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