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Assisted Living Survey Process Part 2

Plans of Correction


Assisted Living Survey Process Part 2

Documenting and executing on your corrective action plan will help position your organization well for future inspections.

Barry Yee

While state regulations differ in regards to assisted living facilities, expect that a survey process of some sort is in place in every state.

By way of example, we are using the State of Wisconsin Department of Health Services survey guides as an example. In our first article we provided an overview of the survey process. In this article we look at plans of correction, actions you may need to take as a result of surveyor findings.

Established completion dates may be set by the state or it may be specified that the plan of correction be reviewed the next time an assisted living surveyor is at the facility.

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

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

Facilities must submit a plan of correction (POC) for each violation identified in the statement of deficiency. Plans of correction must be completed and mailed to the appropriate regional office within 30 calendar days following receipt of the statement of deficiencies.

Each Plan of Correction must address 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?
  • Department Orders, if applicable. Submit documentation, if requested.
  • Date of completion for each corrective action (Violation, Order).

Failure to submit a plan of correction is typically a violation of statutory order and could result in further sanctions.

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

States will also entertain granting an exemption from certain requirements. Sometime an alternative means of meeting a requirement will be requested.

While states vary, a typical process for requesting a waiver my look like this:

  • Request waiver.
  • Specify the rule from which the waiver is requested; the time period for which the waiver is requested; the reason for the request.
  • Supply alternative actions proposed if a variance is requested, or the specific consumers or rooms affected if a waiver is requested.
  • Document that consumer health, safety or welfare will not be adversely affected.

The state will grant or deny a request, in writing, as allowed by the applicable regulation for each provider type. They may grant a waiver when it is demonstrated to the satisfaction of the department that granting it will not jeopardize the health, safety, welfare, or rights to any consumer.

The state may modify the terms of a waiver, impose conditions, or limit its duration. And it may revoke a previously approved waiver, approval, variance, or exception if:

  • It determines that continuance will adversely affect the health, safety, or welfare of the consumers.
  • The facility fails to comply with the conditions imposed.
  • It is required by a change in state or federal law, or by administrative rule.
  • The licensee notifies the department in writing that it wishes to relinquish the waiver.

Each year, the American Health Care Association / National Center for Assisted Living publishes a regulatory update on states that have reported making statutory, regulatory, or policy changes impacting assisted living/residential care communities. It is worth reviewing. They are also a good source for keeping abreast of quality initiatives that can improve your organization.

Also keep in mind that a few states have more than one agency involved in conducting inspections or a different agency than the licensing agency may conduct inspections. For example, in Iowa, the Department of Elder Affairs develops rules and regulations while the Department of Inspections and Appeals, Health Facilities Division monitors, inspects and enforces regulations.

Most states require that assisted living facilities be inspected annually, biannually, biennially, or at a specified time between one and two years, as well as on complaint by a resident, family member. In most states, facility administrators and staff are aware that the department will conduct an initial inspection within a certain time frame. However, subsequent periodic inspections and complaint investigation inspections are usually unannounced.

Use this article as one resource in preparing for the survey. Talk to other providers and also carefully review your particular state regulations. And of course read our blog on this site for up-to-date information. At the end of the day this is about providing a quality of life for residents. If you have been doing the right things all along, you should have no worries. Make sure to communicate positive survey results to residents and families as well as these become marketing tools for you as well.

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