The Survey History area of the Provider Search application provides information on surveys that were conducted at health care and assisted living facilities, except for hospital providers. Surveys conducted by the Division of Quality Assurance (DQA) occurring in the past three years are displayed.
The Survey History area includes:
Information about the types of surveys conducted (e.g., recertification survey, complaint investigation, verification visit);
Survey exit dates;
Statements of Deficiency (SODs)/Notices of Non-Compliance;
Provider's Plans of Correction (POCs)/Statements of Compliance; and
A message will display if no survey information is available for a provider. Survey information for providers that have branch and satellite locations is only displayed under the main provider's location. The Survey History area of branch and satellite locations will provide a link to the provider's main location webpage to view survey information.
Listed below is additional information about the survey process and on how to read/interpret information that is available in the Survey History area.
Surveys are conducted by professional staff from the DQA, referred to as surveyors. During a survey, surveyors determine a provider's compliance with Wisconsin state licensure laws and/or federal Medicare and Medicaid regulations. Surveyor visits are conducted for a variety of reasons, such as standard recertification and licensure surveys, follow-up verification visits, and complaint and incident or abuse investigations.
Most surveys occur unannounced, and are conducted onsite at the facility. The frequency of surveys varies by provider type and is determined by state licensure laws and federal requirements. Factors such as complaints filed against the provider and the provider's past survey compliance may also determine the frequency of surveys conducted.
Surveyors document violations of state laws and federal requirements on a Statement of Deficiency (SOD) form CMS-2567. When issuing a SOD, DQA may require the provider to submit a written plan of correction (POC) addressing each violation and proposed solutions to correct the problems identified. For registered (not certified) residential care apartment complexes (RCACs), surveys are only conducted to investigate complaints and any problems identified are issued in a notice of non-compliance letter and not on a SOD. The registered RCAC submits a statement of compliance letter instead of a POC.
A verification visit (or follow-up) survey may occur to determine if deficiencies previously cited have been corrected. During a verification visit survey it is possible additional deficiencies could be cited.
There could be one or more reasons why a survey is conducted. The Survey Type column in the Survey History area will identify the reasons why the survey was conducted. The initial comments section on the Statement of Deficiency report may provide additional information indicating why the survey was conducted.
Several provider types require both a Health survey and a Life Safety Code (LSC) survey. During a LSC survey a professional engineer or architect surveyor will review whether the life safety code requirements as established by the National Fire Protection Association (NFPA) are met. The LSC inspection covers a wide range of fire protection aspects, including construction, fire suppression, and operational features designed to provide safety from fire.
The following provider types require LSC inspections:
- Nursing Homes
- Facilities for persons with Development Disabilities (FDD)/ Intermediate Care Facilities for Individuals who are Intellectually Disabled (ICF/IID)
- End Stage Renal Dialysis Centers
- Ambulatory Surgical Centers
For these provider types, the Survey Type column will identify each survey as either a Health survey or a Life Safety survey followed by the reason for the survey.
A survey may last several days. The Exit Date column of the Survey History area identifies the last day of the survey.
Statement of Deficiency
Survey findings are documented on a Statement of Deficiency (SOD) form CMS-2567. A "deficiency" is a violation of a specific state or federal regulation. When a deficiency is noted by the surveyor, the specific reasons for the deficiency are documented in the SOD. Some SODs may be very lengthy.
The top of each page of a SOD identifies information about the provider including an identification number, and the provider name and address. The top right-corner identifies the date the survey was completed, or exit date.
Each deficiency is identified by a separate tag code that is listed in the first column (X4) ID Prefix Tag of the SOD. The only exception is the Initial Comments tag which is the first tag listed on the SOD. The Initial Comments tag is used to identify the reason for the survey and may also provide a brief summary of the survey findings.
One survey may result in more than one SOD being issued. SODs that contain tags for state deficiencies, or specific violations of state rule or law, are issued on a separate SOD from deficiencies identifying federal deficiencies. Life safety code deficiencies are also issued on a separate federal SOD. A life safety code SOD documents violations discovered relating to the physical condition of the property. These could include electrical hazards, ventilation problems, and so on.
To view a SOD, select a link under the Statement of Deficiency column in the Survey History area. The link will identify the SOD as either State or Federal.
Nursing Homes Only - Federal Deficiencies
For every federal deficiency cited at a nursing home, surveyors determine the seriousness of the deficiency for the residents in the nursing home. This is called "assigning scope and severity." This process reflects both how serious and how often a problem occurs in the nursing home. Deficiencies range in scope and severity from isolated violations with no harm to residents to widespread violations that cause injuries or put residents in immediate jeopardy of harm or death.
The tag code is followed by SS and a letter in the X4 column of the SOD. SS is an abbreviation for scope and severity. SS levels are placed on federal deficiencies based on the following scope and severity/harm grid:
|Immediate jeopardy to resident health or safety||J||K||L|
|Actual harm that is not immediate jeopardy||G||H||I|
|No actual harm with the potential for more than minimal harm that is not immediate jeopardy||D||E||F|
|No actual harm with potential for no more than minimal harm||A||B||C|
Nursing Homes and FDDs/ICF-IID Only - State Deficiencies
State deficiencies issued at nursing homes and facilities serving people with developmental disabilities (FDDs), also known as Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), are cited as class violations. The deficiency text will indicate the state class violation for each state tag cited. Listed below is information about state class violations:
Class A - Violation of a state code creating "a substantial probability that death or serious mental or physical harm to a resident will result therefrom."
Class B - Violation of state code "directly threatening to the health, safety, or welfare of a resident."
Class C - Violation of a state code that "does not directly threaten the health, safety or welfare of a resident." A Class C violation is issued if the same code was cited within the previous 24 months or if an Order to Correct was not corrected at the verification visit.
Correction Order - Order to Correct: A Class C level violation that was not cited in the previous 24 months.
Plan of Correction
For most deficiencies issued, the provider is required to submit a plan of correction to describe the action they will take to address the cited deficiency, how they will maintain regulatory compliance, and a date of completion for correcting each deficiency. The provider's Plan of Correction (POC) will identify the tag code cited followed by a description of how they will reach compliance. The POC is documented on either the SOD (Form CMS-2567) or on the Plan of Correction Form (F-00344).
To view a POC, select a link under the Plan of Correction column in the Survey History area. The link will identify if the POC is for State or Federal deficiencies cited.
Assisted Living Facilities Only
On January 1, 2010, the Bureau of Assisted Living implemented a policy to no longer require the traditional plan of correction for violations that did not result in enforcement. (For this purpose, "enforcement" includes forfeitures, department orders, special orders, no new admission orders, impending revocation, or licensure/certification revocation.) Instead of the traditional plan of correction, the assisted living facility will submit a plan of correction via attestation using an Attestation of Correction, F-02172 or following this process:
1. The provider's representative will complete the following statement which will be stamped on page 1 of the SOD:
"On behalf of ____________________ (name of facility) the undersigned attests that all deficiencies have been or will be corrected effective _____________ (date)."
2. The provider must then sign and return only page 1 of the Statement of Deficiencies to DQA. No additional information will be required.
Facilities who receive e-SODs will submit their compliance completion date on an Attestation of Correction, F-02172 and not on the SOD.
In lieu of submitting a traditional plan of correction, it is the Department of Health Service's expectation that assisted living facilities will continue to evaluate systems to ensure continued compliance.
Enforcement actions or penalties, sometimes also referred to as remedies, may be imposed on a provider depending on the seriousness of deficiencies issued and the length of time it takes the provider to correct deficiencies. The type of provider also determines what penalties can be enforced.
DQA issues enforcement actions for providers that are state licensed. The federal Centers for Medicare and Medicaid Services (CMS) usually imposes final enforcement actions for providers that participate in the Medicare and/or Medicaid programs. Examples of remedies include placement of a state monitor, directed inservice training, denial of payment for new admissions or civil money penalties. Failure of a provider to correct deficiencies could lead to termination of the provider from the Medicare/Medicaid programs and/or closure.
Enforcement documents will be displayed under the Enforcement column in the Survey History area for surveys resulting in penalties being imposed.
Additional Survey Information
Information about specific state rules and federal regulations for each provider type can be accessed on the Regulation of Health and Residential Care Providers webpage. Select a specific provider type from this web page and you will be directed to web pages containing information pertaining to that provider.
Listed below are links to Survey Guides by provider type. These guides provide additional information about the survey process.
- Assisted Living Facility Survey Guide, P-63186 (PDF)
- AODA and Mental Health Program Certification Survey Guide, P-63174 (PDF)
- Facilities Serving People with Developmental Disabilities Survey Guide, P-63051 (PDF)
- Home Health and Hospice Licensure and Certification Survey Guide, P-63075 (PDF)
- Hospitals and Other Health Services Providers Survey Guide, P-62033 (PDF)
- Nursing Home/Long Term Care Facilities Survey Guide, P-62014 (PDF)
- Personal Care Agency Survey Guide, P-00191 (PDF)
- Survey Guide for Clinical Laboratories, P-01227 (PDF) and refer to Appendix C of the State Operations Manual
Additional Consumer-related Information
- Filing a Complaint about a Health/Residential Care Provider
- Provider Types Regulated by the Division of Quality Assurance
- Consumer Guide to Health Care
- Choosing Residential Care Options
- Guidelines for Assisted Living Enforcement, P-63200 (PDF)
Division of Quality Assurance
PO Box 2969
Madison, WI 53701-2969