DQA/Bureau of Assisted Living
Northeastern Regional Office
Laurie Arkens

• Adult Family Homes
• Community Based Residential Facilities
• Residential Care Apartment Complexes

Top Ten Citations CBRF (Jan. - June 2011)
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 ADEQUATE
TREATMENT
RIGHTS OF RESIDENTS: TO RECEIVE MEDICATION
PRN PSYCHOTROPIC MEDICATION
LISTED AREAS FOR ASSESSMENTS
CAREGIVER: INVESTIGATING ABUSE AND NEGLECT
BATH AND TOILET AREAS: WATER TEMPERATURE
16
16
19
18
19
21
22
21
25
27
30

Top Citations - AFH (Jan - June 2011
)
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
7
7
7
7
7
9
10
10
12
13
15
16
17

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

• 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.

• 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

• 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….

• Training
• Mentoring
• Peer Review
• Resources
• Consultation

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

• 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

• Organizational commitment
• Licensee self attestation

Department Website Resources
• Survey Guide http://www.dhs.wisconsin.gov/publications/p6/p63186.pdf
• Post Survey Questionnaire https://doa.wi.gov/dhssurveys/TakeSurvey.aspx?SurveyID= ml00584
• Enforcement Guidelines http://www.dhs.wisconsin.gov/publications/p6/p63200.pdf
• Strategies to Promote Regulatory Compliance http://www.dhs.wisconsin.gov/rl_dsl/Providers/resources.ht
m

Department Website Resources
• Medication Management Initiative http://www.dhs.wisconsin.gov/rl_dsl/MedManagement/asstlvgMMI.h
tm
• The Assisted Living Forum http://www.dhs.wisconsin.gov/rl_dsl/Providers/asstdLvgForum.htm
• Assisted Living Home Page http://www.dhs.wisconsin.gov/bqaconsumer/AssistedLiving/AsLivin dex.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