Conversations with BALOctober 26, 2011

DQA/Bureau of Assisted Living Northeastern Regional Office

Laurie Arkens

Top 10 Cites for First 6 Months of 2011

• Adult Family Homes

• Community Based Residential Facilities

• Residential Care Apartment Complexes

Top Ten Citations CBRF (Jan. - June 2011)

30

27

25

22

21

21

19

19

18

16

16

LICENSEE ENSURES FACILITY COMPLIES WITH LAWS

SERVICE PLANS UPDATED ANNUALLY OR ON CHANGES

OTHER EVACUATION DRILLS

COMPREHENSIVE INDIVIDUALIZED SERVICE PLAN

CONTINUING EDUCATION

RIGHTS OF RESIDENTS: PROMPT AND ADEQUATETREATMENT

RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION

PRN PSYCHOTROPIC MEDICATION

LISTED AREAS FOR ASSESSMENTS

CAREGIVER: INVESTIGATING ABUSE AND NEGLECT

BATH AND TOILET AREAS: WATER TEMPERATURE

Top Citations - AFH (Jan - June 2011)

17

16

15

13

12

10

10

9

7

7

7

7

7

RESPONSIBILITIES

HOME ENVIRONMENT

REVIEW OF ISP

SAFE PHYSICAL ENVIRONMENT

TRAINING-8 HOURS ANNUALLY

SMOKE DETECTORS-TESTING AND MAINTENANCE

FIRE EVACUATION ANNUAL EVALUATION

TRAINING-15 HOURS WITHIN 6 MONTHS

FREE OF HAZARDS

ANNUAL WELL WATER INSPECTIONS

FIRE SAFETY-SMOKE DETECTORS

EXITING FROM THE FIRST FLOOR

FIRE SAFETY EVACUATION PLAN REVIEW

Strategies

Strategies to Promote Regulatory Compliance:

• Adult Family Homes

• Community Based Residential Facilities

• Residential Care Apartment Complexes

*Based on Top 10 Cites for Calendar Year 2010

Abbreviated Survey

• Recognize communities with good compliance history

• Use all senses - if it feels good, looks good, smells good, sounds good… move on!

The Next Generation of the WI Survey Process ….

Proposal - less frequent reviews of providers with good compliance

• Criteria– Facility qualifies for an abbreviated survey and;

– Facility is a member of a major association in good standing (WALA, WAHSA, WiCAL, RSA of WI, WADSA) and;

– Facility has implemented a “provider association”, “department approved”, quality improvement program that adopts standards of practice and;

– Facility has signed a department “self attestation” document that they are in substantial compliance of the regulations.

Events so far …..

• Approval from DHS Secretary

• Met with Associations and Advocates

• BAL Developed Guiding Values

• Partnership with UW Madison for a research component

• Updated DQA database to recognize this new group

Next Steps …..

• Meeting to update the associations• DQA/UW Madison grant applications to

help fund the start up and the research component

• Associations to complete their comprehensive plan and submit to DQA/BAL for approval

• Associations to help members implement• Study the effectiveness

WI Coalition for Collaborative Excellence in Assisted Living

• Provider Association Sponsored

• Department Approved

• Comprehensive QA & QI

• Includes the following Guiding Values….

Provider Association Support

• Training• Mentoring• Peer Review• Resources• Consultation

Standards of Practice• ADLs• Diabetes• Dementia• Pain• Pressure ulcers• Person-centered care• Abuse, neglect• Falls• Mental Health• Infection control• Emergency Management• Medication• Food safety

Regulatory Compliance

• WI Administrative Code

• State Statute

Activities & Community Involvement

• Active• Involved• Connected

Consumer & Advocate Feedback

• Residents/Tenants• Families/legal rep.• Staff• Case Managers/Funding• Councils, surveys,

grievance process, questionnaires

Leadership & Workforce Support

• Leaders• Competency• Professional growth• Recruitment• Retention

Continuous Quality Improvement

• Benchmarks• Data Collection• Performance analysis• Continuous

Commitment

• Organizational commitment

• Licensee self attestation

Department Website Resources

• Survey Guidehttp://www.dhs.wisconsin.gov/publications/p6/p63186.pdf

• Post Survey Questionnairehttps://doa.wi.gov/dhssurveys/TakeSurvey.aspx?SurveyID=ml00584

• Enforcement Guidelineshttp://www.dhs.wisconsin.gov/publications/p6/p63200.pdf

• Strategies to Promote Regulatory Compliance http://www.dhs.wisconsin.gov/rl_dsl/Providers/resources.htm

• Medication Management Initiativehttp://www.dhs.wisconsin.gov/rl_dsl/MedManagement/asstlvgMMI.htm

• The Assisted Living Forumhttp://www.dhs.wisconsin.gov/rl_dsl/Providers/asstdLvgForum.htm

• Assisted Living Home Pagehttp://www.dhs.wisconsin.gov/bqaconsumer/AssistedLiving/AsLivindex.htm

• DQA Memos, ListServ, CBRF Training, CBRF Administrator’s Course, Family Care, Consultant List, Assisted Living Directories and Profiles, Resident Relocation Information, Forms (Fire Report, Evacuation Assessment Form, Licensure Checklists), OCQ Information, & MORE

Department Website Resources

Questions/Answers