Assisted Living Survey Guide

The Division of Quality Assurance conducts both announced and unannounced surveys of assisted living facilities, including community-based residential facilities (CBRFs), residential care apartment complexes (RCACs), adult family homes (AFHs), and adult day care centers (ADCCs) in Wisconsin to ensure that state licensure/certification and home and community-based services (HCBS) requirements are met.

Overview

Assisted living surveyors evaluate a facility’s performance and compliance with applicable laws and standards in the areas of resident rights, program services, nutrition and food service, physical environment and safety, medication, and staff training. The assisted living survey may be one of seven types:

  • Initial and/or Technology-Based: An initial survey process is conducted to evaluate structural requirements, such as building construction and design related to safety, accessibility, and environmental issues. Process requirements that must be present for desirable outcomes for residents, tenants, and participants (hereinafter termed “consumers”) are also evaluated. 

    For assisted living providers who have been licensed or certified before by DQA and have good compliance history will qualify for a technology-based initial licensing or certification survey utilizing DHS technology. 
     
  • Abbreviated: This process will be used in situations for facilities with good compliance history that meet the following criteria:
    • No enforcement activity within the last three years.
    • Must have received a standard survey since initial licensure or certification.
    • No substantiated complaints, resulting in deficiencies, within the last three years.
    • Facility has been licensed or certified for at least three years.

Regional supervisory discretion may address individual cases where an exception may be made to the identified survey type.

The abbreviated survey process focuses on observations and interviews. Observations and interviews are used to evaluate how the individual needs and preferences of consumers are met. If concerns are not identified through observations and interviews, the survey may be concluded. If concerns are identified, the surveyor will continue to investigate.

  • Standard: This process will be used when a facility does not meet the criteria for an abbreviated or initial survey. Observation and interview techniques will be primarily used to gather data during the on-site visit. Review of consumers’ records and facility records will be done as needed to further investigate concerns identified by observation and interview findings and to determine compliance with process requirements.
  • Complaint: This process will be used when DQA/BAL receives a complaint regarding possible violation of Wisconsin and/or HCBS regulations. The complaint investigation is a focused process that utilizes any of the assisted living survey tasks to investigate the allegations.
  • Verification: This process will be used when DQA/BAL issues violations of Wisconsin regulations and needs to confirm compliance by conducting an on-site survey of the facility. The verification survey may include all of the assisted living survey tasks.
  • Self-Report: This process will be used when DQA/BAL triages a self-report to be investigated. The self-report investigation is a focused process that utilizes any of the assisted living survey tasks to investigate the concerns.
  • Monitoring: This process will be used when DQA/BAL has general regulatory concerns regarding the operations of the assisted living facility and needs to confirm the health, safety and well-being of the consumers.

Survey Process Types

Initial Survey Process

An initial survey process is used for the issuance of a new license or certification with a strong emphasis on the provision of technical assistance to the new provider. A completed application is necessary to begin the process. The application is reviewed to determine if an applicant is “fit and qualified,” meets financial stability criteria, and if the facility is ready for an on-site visit. This review is done off-site. The materials required to be submitted prior to an initial on-site survey vary according to provider type.

An initial survey process emphasizes structural requirements, such as building construction, design, and approvals related to safety, accessibility, and environmental issues. Compliance with process requirements will be reviewed and technical assistance may be provided.

Abbreviated Survey Process

A facility meets the criteria for an abbreviated survey if it has not had any enforcement action in the last three years, received a standard survey since initial licensure or certification, has not had any substantiated complaints with deficiencies issued in the last three years, and has been licensed for at least three years.

The abbreviated survey process consists of the following steps:

  1. Off-Site Survey Review: This task is conducted off-site and establishes the type of survey to be conducted. The purpose is to gain an understanding of the facility client group served, compliance and complaint history, any changes since the last survey, and any areas of concern.
  2. Introductory Meeting with Staff in Charge: The purpose of this task is to make introductions, explain the survey process, and request needed materials. The surveyor provides the licensee or designated representative a link to the Survey Guide, a checklist that identifies documents needed for review during the survey process, and a post-survey questionnaire. This is a brief task that provides an overview of the consumer population and the services the facility provides.
  3. Tour: The surveyor tours the facility with staff, if available. During the tour, the surveyor will talk with as many staff and consumers in order to gather a general understanding of the level of services provided by the facility and the consumers’ perception of the services received.
  4. Observations: This task builds on the general observations made during the tour. Observations focus on consumers during varying times and settings. These observations evaluate if the facility promotes and protects rights and dignity and evaluates how the consumers’ needs and preferences are met. In addition, observations are made for homelike environment and physical safety.
  5. Interviews with Consumer, Family Members/Representatives, and Staff: Interviews will be conducted to determine how the consumers, family members/representatives, and staff perceive the services delivered by the facility and to clarify information gathered during observations. Interviews are informal and conducted in a private location.
  6. Record Review: The purpose of the record review is to confirm or obtain needed information to make compliance decisions. Consumer and personnel records will be checked for compliance with certain process requirements. Consumer assessments and staff training are examples of process requirements.
  7. Safety Code Review: The safety code review expands beyond the initial tour and focuses on environmental safety. This review may include a review of fire safety compliance, evacuation, storage of hazardous materials, and required inspections.
  8. Technical Assistance, Standards of Practice, and Assisted Living Facility Quality Improvement: This task promotes the quality of life and care by adding value to the regulatory process through the provision of technical assistance to providers and the promotion of standards of practice.

Technical assistance includes, but is not limited to:

  • Interpretation of licensing and certification requirements.
  • Guidance related to consumer quality of life and care.
  • Review of provider systems, processes, and policies within the context of regulatory requirements.
  • Provision of information regarding noncore code issues.
  • Provision of information regarding new or innovative programs adding quality of life and care.
  • Provision of information related to available resources.

Technical assistance does not relieve providers of their responsibility to comply with the regulations. Facilities remain subject to regular survey and enforcement activities, regardless of having received technical assistance services.

Standards of practice apply to all provider types and are authoritative statements or guidelines that are nationally recognized and serve as a standard of measure or value. The assisted living surveyor may promote the use of standards of practice in the following ways:

  • Provide information related to available resources.
  • Acknowledge the positive impact of standards of practice on consumer’s quality of life and care.
  • Recognize the successful use of standards of practice.

Assisted Living Facility Quality Improvement 

  • Collect and analyze data (consumer/legal representative satisfaction, mock surveys, tracking/trending, falls, hiring/admission, caregiver misconduct, etc.).
  • Detect and/or respond to violations of state licensing and certification assisted living regulations.
  • Continuously evaluate assisted living facility systems, processes, and polices.
  1. Exit Conference: Throughout the survey process, the surveyor will inform staff of identified issues and seek additional information about the issue. At the completion of the survey, the surveyor will conduct an exit conference with the licensee or designated representative. The general objective of this meeting is to explain the preliminary findings and areas of concern.

During the exit conference, the surveyor will inform the provider the Bureau is no longer regularly requiring a Plan of Correction. The surveyor will communicate that the provider should have an internal system to correct the violations. If additional focused technical assistance is necessary, the surveyor may recommend the provider implement an internal system that contains all of the following:

  • What corrective action and system changes will be made to ensure violations are corrected and regulatory compliance is maintained?
  • Who is responsible for monitoring for continued regulatory compliance?
  • When will compliance be achieved?
  • Collect and analyze data on consumer/legal representative satisfaction, mock surveys, tracking/trending (falls, hiring/admission, caregiver misconduct, etc.).
  • Detect/Respond to violations of state licensing/certification assisted living regulations.
  • Continuously evaluate assisted living facility systems, processes, and polices.

Standard Survey Process

The standard survey process is used in facilities that do not meet the criteria for an abbreviated or initial survey. The standard survey process consists of the following steps:

  1. Off-Site Survey Review: This task is conducted off-site and establishes the type of survey to be conducted. The purpose is to gain an understanding of the facility client group served, compliance and complaint history, any changes since the last survey, and any areas of concern.
  2. Introductory Meeting with Staff in Charge: The purpose of this task is to make introductions, explain the survey process, and request needed materials. The surveyor provides the licensee or designated representative a link to the Survey Guide, a checklist that identifies documents needed for review during the survey process, and a post-survey questionnaire. This is a brief task that provides an overview of the consumer population and the services the facility provides.
  3. Tour: The surveyor tours the facility with staff, if available, and meets as many consumers and staff as possible. During the tour, the surveyor focuses on consumer rights, dignity and privacy, the environment and safety.
  4. Sample Selection: The purpose of this task is to draw a sample of consumers receiving services.
  5. Observations: This task builds on the general observations made during the tour. Observations focus on the sampled consumers during varying times and settings. These observations evaluate if the facility promotes and protects consumer rights and dignity and evaluates how the consumers’ needs and preferences are met. In addition, observations are made for homelike environment, physical safety, medication system, and kitchen.
  6. Interviews with Consumer, Family Members/Representatives, and Staff: Interviews will be conducted to determine how the consumers, family members/representatives, and staff perceive the services delivered by the facility and to clarify information gathered during observations. Interviews are informal and conducted in a private location.
  7. Record Review: The purpose of the record review is to confirm or obtain needed information to make compliance decisions. Consumer and personnel records will be checked for compliance with certain process requirements. Consumer assessments and staff training are examples of process requirements.
  8. Safety Code Review: The safety code review expands beyond the initial tour and focuses on environmental safety. This review may include a review of fire safety compliance, evacuation, storage of hazardous materials, and required inspections.
  9. Technical Assistance, Standards of Practice and Assisted Living Facility Quality Improvement: This task promotes the quality of life and care by adding value to the regulatory process through the provision of technical assistance to providers and the promotion of standards of practice.

Technical assistance includes, but is not limited to:

  • Interpretation of licensing and certification requirements.
  • Guidance related to consumer quality of life and care.
  • Review of provider systems, processes, and policies within the context of regulatory requirements.
  • Provision of information regarding noncore code issues.
  • Provision of information regarding new or innovative programs adding quality of life and care.
  • Provision of information related to available resources.

Technical assistance does not relieve providers of their responsibility to comply with the regulations. Facilities remain subject to regular survey and enforcement activities, regardless of having received technical assistance services.

Standards of practice apply to all provider types and are authoritative statements or guidelines that are nationally recognized and serve as a standard of measure or value. The assisted living surveyor may promote the use of standards of practice in the following ways:

  • Provide information related to available resources.
  • Acknowledge the positive impact of standards of practice on consumer’s quality of life and care.
  • Recognize the successful use of standards of practice.

Assisted Living Facility Quality Improvement

  • Collect and analyze data (consumer/legal representative satisfaction, mock surveys, tracking/trending, falls, hiring/admission, caregiver misconduct, etc.).
  • Detect/Respond to violations of state licensing/certification assisted living regulations.
  • Continuously evaluate assisted living facility systems, processes, and polices.
  1. Exit Conference: Throughout the survey process, the surveyor will inform staff of identified issues and seek additional information about the issue. At the completion of the survey, the surveyor will conduct an exit conference with the licensee or designated representative. The general objective of this meeting is to explain the preliminary findings and areas of concern.

During the exit conference, the surveyor will inform the provider the Bureau is no longer regularly requiring a Plan of Correction. The surveyor will communicate the provider should have an internal system to correct the violations. If additional focused technical assistance is necessary, the surveyor may recommend the provider implement an internal system that contains all of the following:

  • What corrective action and system changes will be made to ensure violations are corrected and regulatory compliance is maintained?
  • Who is responsible for monitoring for continued regulatory compliance?
  • When will compliance be achieved?
  • Collect and analyze data on consumer/legal representative satisfaction, mock surveys, tracking/trending (falls, hiring/admission, caregiver misconduct, etc.).
  • Detect/respond to violations of state licensing/certification assisted living regulations.
  • Continuously evaluate assisted living facility systems, processes. and polices.

Decision-Making

Following the survey, the assisted living surveyor, along with his or her supervisor, will determine if a citation should be issued, and whether to submit a citation for enforcement review. 

Survey results could be documented as one or a combination of the following:

  • No Deficiencies: No state violations were identified and issued.
  • Statement of Deficiency: Used to identify incidents of noncompliance that:
    • Result in more than minimal, but not serious harm.
    • Have potential for more than minimal harm, but not serious harm.
    • Indicate a breakdown in facility systems.
  • Statement of Deficiency with Enforcement: Used to identify incidents of noncompliance that: 
    • Result in serious harm.
    • Have potential for serious harm.
    • Indicate a breakdown in facility systems that could lead to serious harm.
    • Meet the criteria identified in the Assisted Living Enforcement Procedures and Guidelines.

Surveys that result in no deficiencies, statement(s) of deficiency, or statement(s) of deficiency with enforcement are emailed or mailed to the licensee following the exit conference.

In an effort to enhance collaboration with other stakeholders in assisted living, a courtesy copy of the statement of deficiency containing no new admission order, no new admission order extended, or revocation will be emailed to the county, waiver agencies, Division of Medicaid Services (DMS), Disability Rights Wisconsin (DRW), and the ombudsman. All other statement of deficiencies are uploaded to provider search and information is posted on the monthly additions report.

Enforcement

Wisconsin State Statute (Chapter 50) and Wisconsin Administrative Codes grant authority to the Department of Health Services (DHS) to impose sanctions and penalties if regulated assisted living facilities do not comply with applicable laws and regulations.  

To promote the health, safety, and welfare of residents and compel facilities to comply with regulatory requirements, the Division of Quality Assurance may impose the sanctions or penalties afforded by statute or administrative code. These sanctions or penalties are typically categorized as “enforcement.”

Statements of Deficiency (SOD)

The enforcement process begins with a statement of deficiency (SOD). The SOD is the written report that follows a compliance survey or investigation wherein the surveyor documents facts that show regulatory noncompliance. The SOD is a legal record of the surveyor’s findings and forms the basis for enforcement determination. 

Surveyors use the following instructions to write statements of deficiency:

  • Document if the violation is a repeat violation.
  • Verify that the correct regulation has been selected for the deficient practice identified.
  • Describe the violation in clear, understandable terms.
  • Include the specific dates of violation in the report (forfeitures are assessed per date of violation).
  • Provide sufficient detail and corroborate findings using more than one source (e.g., observation, interview, record review).
  • Describe the specific results and consequences of the deficient practice (document adverse outcomes or potential adverse outcomes).
  • Record facts, not opinions
  • Answer:
    • Who was involved?
    • What occurred (or did not occur)?  How did it occur? 
    • What did staff do/not do that led to noncompliance?
    • When?  (date/time)
    • Where? 
    • How were the violation(s) verified? (evidence)
  • Include resident and staff identifiers. Include staff titles if relevant to the deficiency (e.g., “Staff A, Licensee.”)

Citations Subject to Enforcement Review

Assisted living regional directors (ALRD) generally refer to the enforcement specialists any violation that:

  • Results in serious harm, has a potential for serious harm, or indicates a breakdown in facility systems that could lead to serious harm.
  • Creates 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).
  • Creates a condition or occurrence that presents a direct threat to the health, safety or welfare of a resident.

In addition, violations of the following requirements are generally referred to the enforcement specialists for review. 

  • Minimum staff training requirements
  • Safe Environment and Fire Safety: For example, failure to meet requirements for smoke and heat detection systems, resident evacuation assessments, emergency plans and drills, safe building construction, inspection or service requirements, hot water temperatures.
  • Abuse, neglect, misappropriation of property
  • Resident rights
  • Criminal records checks (repeat violations or serious concerns)
  • Prompt and adequate treatment, physician notification, health services: Failure to provide services that contributes to a negative resident outcome (harm), or potential for negative outcome. For example, pressure sores without proper treatment, falls without intervention, pain that is not managed, significant, unplanned weight loss, illness and infections that are not assessed or for which medical attention is not sought, and preventable injuries.
  • Staffing Patterns: Failure to meet staffing requirements. Residents’ needs are not met or safety is compromised due to inadequate staffing.
  • Supervision
  • Medications: For example, residents do not receive medications as ordered or insulin injections are administered by untrained staff in the absence of nurse delegation.
  • Activities: For example, insufficient activity programming, inappropriate activities.
  • Infection control or sanitation concerns, foodborne illness
  • Financial stability: Facility has not paid utility bills; staff are not paid; insufficient groceries; insufficient supplies to meet resident needs.
  • Repeat Violations

Enforcement Analysis and Determination Criteria

The Bureau of Assisted Living enforcement specialists evaluate violations to determine which sanctions to impose, if any, and the amount of any forfeiture to be assessed (based on statute and administrative rule). The enforcement specialist consults with the Office of Legal Counsel and bureau director/deputy director prior to revoking a license and as indicated depending on the scope and complexity of violations under review.

The following factors are considered in determining whether enforcement action will occur, the sanction to be imposed, and the amount of any forfeiture.

  1. The gravity of the violation, including the probability that death or serious physical or psychological harm to a resident will result or has resulted; the severity of the actual or potential harm; and the extent to which the provisions of the applicable statutes or rules were violated.
  2. “Good faith” exercised by the licensee. Indications of good faith include, but are not limited to, awareness of the applicable statutes and regulations and reasonable diligence in complying with such requirements, efforts to correct violations, and other mitigating factors in favor of the licensee.
  3. A provider’s compliance history. Previous violations and repeat violations.
  4. The financial benefit to the facility of committing or continuing the violation.
  5. Sanctions imposed for comparable violations in other facilities.

The enforcement analysis takes into account the extent and seriousness of the deficient practice. For example, the number of consumers affected by the deficient practice and the degree of negative outcome or potential negative outcome, the period of time during which the violation occurred (hours, days, weeks), or the number of locations in which the deficient practice was identified.

Incidents “self-reported” by the licensee that result in violations represent “good faith” and are considered in the enforcement review.

The findings for specific violations vary depending on circumstances, consumers, staff, and other factors. As a result, enforcement determinations for violations of the same code may vary. The enforcement determination and forfeiture amounts, if any, are based on the facts reported in the statement of deficiency.

Compliance Requirements

  • AFH, ADCC, CBRF Only: Effective October 1, 2020, DQA/BAL implemented a no plan of correction initiative. Assisted living providers will have 45 days to correct the violation. Assisted living providers will utilize their internal quality improvement systems to correct the violation(s). BAL may conduct a verification survey after the 45 days have expired.
  • Certified RCAC: For certified residential care apartment complexes (RCAC), when a statement of deficiency with violations is issued, the certified RCAC will have 45 days to correct the violation. In addition, instead of the traditional plan of correction, the certified RCAC will submit a plan of correction via attestation using form Attestation of Correction, F-02172. BAL may conduct a verification survey after the 45 days have expired.
  • Registered RCAC: For a registered RCAC, when violations are identified a letter of noncompliance is issued.

Verification of Correction

The Bureau may verify correction of all citations after 45 days have passed.

Pursuant to Wis. Stat. §§ 50.03(5g)(cm), 50.02(2)(am)2., and 50.034(10), if the Department of Health Services (DHS) imposes a sanction (e.g., special orders, department orders, forfeiture) or takes other enforcement action against a community-based residential facility (CBRF), adult family home (AFH), or residential care apartment complex (RCAC) for a violation of Chapter 50, or rules promulgated under it, and DHS subsequently conducts an on-site inspection to review the facility’s action to correct the violation(s), DHS may impose a $200 inspection fee on the facility.

Pursuant to Wis. Stat. § 49.45(47)(e), if DHS takes enforcement action against a certified adult day care center (ADC) for violating a certification requirement established under § 49.45(2)(a)11 and DHS subsequently conducts an on-site inspection to review the facility’s action to correct the violation(s), DHS may impose a $200 inspection fee on the ADC.

Providers will be notified when revisit fees are due. If revisit fees are not paid in a timely manner, DHS will follow enforcement procedures consistent with non-payment of forfeitures (e.g., issuing a subsequent Statement of Deficiency with additional sanctions.)

Failure to Correct Violations

Failure to correct a citation by the date specified may result in sanctions according to applicable statutes and administrative code provisions, and may include the following:

  • A forfeiture or an increased forfeiture
  • Suspension of admissions
  • Imposed plan of correction by the department
  • Suspension or revocation of the facility’s license

Forfeiture Payment

Unless you file an appeal, you must pay the forfeiture amount within 10 days of receipt of a Notice and Order. Remittance is payable to “DHS 639.”

Appeals

A facility may contest the imposition of a statutory sanction, revocation, or denial of licensure as allowed by statute and administrative code:

  • Adult Family Homes do not have appeal rights for DHS action for any sanction under Wis. Admin. Code § DHS 88.03(6)(g). Adult family homes may appeal license denials, revocations, or suspensions under Wis. Stat. § 50.033(4) and Wis. Admin. Code §§ DHS 88.03(3), DHS 88.03(6)(d), and DHS 88.03(6)(e).
  • Community-Based Residential Facilities have appeal rights for DHS action for all sanctions under Wis. Stat. § 50.03(5g).
  • Certified Residential Care Apartment Complexes have appeal rights for DHS action for all sanctions under Wis. Stat. § 50.034 and Wis. Admin. Code §§ DHS 89.53(2)(c), DHS 89.53(2)(d), DHS 89.53(4)(b), DHS 89.56, and DHS 89.57.
  • Home and Community-Based Services (HCBS) providers do not have appeal rights for noncompliance with HCBS requirements.

Appeal rights, if applicable, along with instructions on where to submit an appeal, are provided in the Notice and Order that accompany a Statement of Deficiency.

Waivers, Approvals, Variances, and Exceptions (WAVE)

Definitions

  • Waiver: The granting of an exemption from a requirement of Wisconsin Administrative Code.
  • Approval: Review and approval by DHS of a practice before the facility implements such.
  • Variance: Allowing an alternative means of meeting a requirement of Wisconsin Administrative Code.
  • Exception: Granting the omission of a requirement of Wisconsin Administrative Code.

Submitting a WAVE Request

  1. WAVE requests may be submitted at any time. The request should be sent to the assisted living regional director at the address listed on our website. Please see Waivers, Approvals, Variances, and Exceptions: Assisted Living for instruction on completing a WAVE request. The request must be in writing and include:
  • The rule from which the WAVE is requested.
  • The time period for which the WAVE is requested.
  • The reason for the request.
  • The alternative actions proposed if a variance is requested, or the specific consumers or rooms affected if a WAVE is requested.
  • Documentation of assurance that consumer health, safety or welfare will not be adversely affected.
  1. DHS will grant or deny a request in writing, as allowed by the applicable regulation for each provider type. DHS may, in its sole discretion, grant a WAVE of a requirement when it is demonstrated to our satisfaction that granting the WAVE will not jeopardize the health, safety, welfare, or rights to any consumer.
  2. DHS may modify the terms of the WAVE, impose conditions on the WAVE, or limit the duration of any WAVE.

Revoking a WAVE

DHS may revoke a previously approved waiver, approval, variance, or exception if:

  1. It determines that continuance of the WAVE adversely affects the health, safety, or welfare of the consumers.
  2. The facility fails to comply with the conditions imposed on the WAVE.
  3. It is required by a change in state or federal law, or by administrative rule.
  4. The licensee notifies DHS in writing that it wishes to relinquish the WAVE.
Last Revised: October 14, 2020