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:
- 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:
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: March 29, 2011 |
