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Wisconsin Department of Health Services

Division of Quality Assurance
(608) 266-8481

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Glossary - Assisted Living Facility Profiles

IMPORTANT: Please review the information on this page and the Basic Information on Facility  Profiles before accessing the lists of provider profiles.

The following is a glossary of terms for the facility profile. The Glossary of Terms are divided into four categories to match the order in which the terms appear on the profile.

1. Facility Name and Status

Identifies the name and address of the facility. Also see Assisted Living Facility Directories and Glossary of Terms

License Status: Regular or Probationary. The Department issues all assisted living facilities a “regular” license/certificate/registration, except CBRFs, which are issued a “probationary” license for the first year of operation.

Licensed/Certified/Registered: The date provided indicates when the facility received their initial license/certification/registration. CBRFs and AFHs are licensed, ADCs are certified, and RCACs may be certified or registered.


2. Survey History

Assisted living facilities are surveyed by the Division of Quality Assurance (DQA) approximately every two years to ensure compliance with applicable Wisconsin Administrative Codes, statutes and standards.

Additional reviews may be conducted as part of complaint investigations, verification visits and follow up to facility self-reports.

The Survey History section of the profile report captures all survey activity completed during the reporting period identified 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 conducted prior to issuing a facility’s first license/certification.

  • Abbreviated: At DQA’s discretion, the abbreviated survey process is used for facilities with a compliance history that meets the following three criteria:

    • No enforcement activity within the last three years;
    • No substantiated complaints, resulting in deficiencies, within the last three years; and
    • Facility has been licensed/certified for at least three years.

  • Standard: A standard survey process is used in facilities that do not meet the criteria for an abbreviated or initial survey.
  • Other: Complaint, self-report or verification visit.

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

Results: Action taken by the Department in response to the inspection. Following are the possible results:

  • Issuance of a license/certificate

  • No Statement of Deficiency

  • Statement of Deficiency

  • Enforcement

Statement of Deficiency: Used to identify incidents of non-compliance that:

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

All Statements of Deficiency will include a sanction for an order to submit a plan of correction within 30 days (see Wis. Admin. Code § HFS 83.07(14)(a)).

Served: Date licensee receives the Statement of Deficiency

Deficiencies Cited: The code reference from the Wisconsin Administrative Code, statute or standard for the incident of non-compliance.

Subject Area: Description title of the referenced Wisconsin Administrative Code, statute or standard.

Compliance Verified: Date DQA verifies correction of the non-compliance. If this item is empty, then verification of the non-compliance has not occurred.

Corrected: This item will contain a "yes," "no," "variance," "waiver," "Admin. Code Revision," or "withdrawn" response, or may be blank.

  • 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.
  • Variance: The facility requested and was issued a variance allowing an alternative means of meeting the requirement.
  • Waiver: The facility requested and was issued a waiver granting an exemption from the requirement.
  • Administrative Code Revision: On 4/1/09, revised Wisconsin Administrative Code, Chapter DHS 83 became effective.  Codes that were cited prior to 4/1/09 may no longer be the same code under the revised DHS 83.  Therefore, an onsite verification visit was not conducted to determine the status of the deficiency and the deficiency has been closed without action.
  • Withdrawn: As a result of litigation (appeal), the Department withdraws the citation.
  • (Blank/Empty): The Department has not completed a verification visit to determine compliance.

3. Enforcement History

Information contained in this portion of the facility profile identifies an occurrence from the Survey History section of the profile that resulted in DQA issuing a sanction against the facility. Deficiencies resulting in enforcement action include those that:

  • Result in serious harm, has a potential for serious harm, or indicates 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 result (or did occur);
  • Create a condition or occurrence that presents a direct threat to the health, safety or welfare of a resident.
  • Repeated, uncorrected, or “target” violations. For example, violations of staff training requirements are “target” violations that result in enforcement action.

See Guidelines for Assisted Living Enforcement (PDF, 91 KB) for more information.

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 through an appeal to the Division of Hearing and Appeals. Appeals may be resolved via stipulated settlement agreements or may go to hearing before an administrative law judge.

Decision: Result of the appeal process which could be one of the following:

  • Pending (department 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 (hearing decision rules in favor of a portion of the department’s action and in favor of a portion of the petitioner’s appeal).

Stipulation: A Stipulated Settlement Agreement between the department and petitioner to resolve 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: The DQA has the authority under state law (ch. 50 of the Wisconsin Statutes and applicable Wisconsin Administrative Code) to impose the following penalties:

  • Forfeiture
  • No New Admissions
  • Revocation
  • Orders to Comply With Corrective Action Specified by the Department
  • Order to Obtain Training
  • Order to Stop Violating a Provision of Licensure

4. Complaint History

The Department accepts all complaints against providers over which the Department has authority. 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 do not appear on this profile report.

Date Complaint Received: Date the Department received the letter, telephone call, or e-mail from a complainant.

Date Investigation Completed: Date all aspects of the complaint investigation have been 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 or Notice of Finding was issued.
  • Unsubstantiated: There was no deficient practice identified related to the complaint.

SOD #: If the subject area of a complaint is substantiated and results in the issuance of a Statement of Deficiency, the SOD # will be indicated. Please reference Survey History and Enforcement History for additional information about the SOD.

Disclaimer: Assisted living facility profile information is provided as a public service by the Wisconsin Department of Health Services (DHS). The Department neither endorses any facility nor guarantees that the information is accurate, up-to-date or complete.

This information, which should not be used as a sole source in selecting a facility, does not replace official information sources. The DHS is not responsible for any errors in or omissions from the compliance history information.

Last Revised:  October 14, 2013