WISCONSIN LEGISLATIVE AUDIT BUREAU
AUDIT SUMMARY
Report 02-21
December 2002
REGULATION OF NURSING HOMES AND ASSISTED LIVING FACILITIES
In fiscal year (FY) 2000-01, there were 462 nursing homes and 2,114 assisted
living facilities in Wisconsin. Approximately $1.0 billion in federal and
state Medical Assistance (Medicaid) funds helped to support the cost of care provided to
residents.
The Department of Health and Family Services regulates both nursing homes and assisted
living facilities, and inspections are its principal regulatory tool. In FY 2000-01,
215.7 full-time equivalent staff in the Department’s Bureau of Quality
Assurance were involved in the regulation of both types of long-term care facilities. The
Department’s expenditures for regulatory staff in five regional offices, including those who
conduct inspections and investigate complaints, totaled $12.5 million.
More Citations Are Being Issued, Particularly for Assisted Living Facilities
Long-term care facilities that violate state or federal regulations are cited by the
Department’s inspectors. During the period we reviewed, the number of citations issued to
nursing homes increased 6.1 percent, from 3,051 in FY 1997-98
to 3,236 in FY 2000-01. In contrast, the number of citations issued to
assisted living facilities increased by 140.3 percent, from 1,865
to 4,482. The increase in assisted living facility citations is nearly nine
times greater than the 15.9 percent increase in the number of these facilities
providing care during this period. It can be attributed, in part, to implementation of new
state regulations. Levels of severity are not specified for assisted living facility
citations, but 37.3 percent of citations issued in community-based
residential facilities and 43.4 percent of citations issued in adult
family homes pertained to physical environment and safety matters that typically do not
involve direct harm to residents.
Complaints about assisted living facilities increased 82.1 percent during the
period we reviewed. In contrast, nursing home complaints decreased 3.0 percent.
The Department partially substantiated 74.3 percent of the 2,061 assisted
living facility complaints it investigated, and 32.9 percent of the 3,792
nursing home complaints for which complete data were available. Substantiated complaints
against assisted living facilities most commonly involved resident rights and resident
abuse, while those against nursing homes most commonly involved quality of care and nursing
services.
Regulatory Oversight Differs for Nursing Homes and Assisted Living Facilities
Under federal regulations, nursing homes are subject to routine, unannounced inspections by
teams of inspectors that must include at least one registered nurse. Wisconsin nursing homes
were inspected, on average, once every 12 months. When both routine inspections and
complaint investigations are considered, each nursing home in Wisconsin was visited an
average of 4.4 times in FY 2000-01. In contrast, as of
June 30, 2001, 47.1 percent of assisted living facilities had not been visited
by inspectors for any reason for at least one year, and 13.3 percent had not
been visited for more than two years.
Regulations governing the oversight of assisted living facilities are established entirely
by the State, and they contain no requirements related to inspection frequency for
community-based residential facilities and adult family homes. Under administrative code,
residential care apartment complexes are to be inspected at least once every three years.
Each assisted living facility inspection typically involves a single inspector who is not
required to have medical credentials.
All Available Enforcement Options Are Not Used
Long-term care facilities that have been cited by the Department are subject to an
enforcement process that can result in financial penalties, restrictions on admissions,
licensure constraints, additional management oversight or control, and criminal charges.
The most commonly used enforcement option is the state forfeiture. From FY 1997-98
through FY 2000-01, the Department imposed a total of 864 forfeitures
on nursing homes that had violated state regulations, and 578 state forfeitures on assisted
living facilities. In FY 2000-01, the average nursing home forfeiture
assessment was $11,246 per citation, and nursing homes were assessed a
total of $1.3 million in state forfeitures. The average forfeiture assessment
for assisted living facilities was $507 per statement of deficiency, and assisted living
facilities were assessed a total of $96,392 in state forfeitures. The Department
has documented a procedure for assessing state nursing home forfeitures, but there are no
criteria in statutes or administrative code for determining assisted living facility
forfeiture amounts.
Although prompt imposition of penalties is considered an effective method of compelling
compliance, most state nursing home forfeitures are not assessed in a timely manner, and
only a portion of the amount assessed is collected because of statutory discounts. Other
penalty options are rarely used. For example, new admissions were restricted in assisted
living facilities but not nursing homes during the period of our review. License revocation
was used against 29 assisted living facilities, but the Department did not revoke or
suspend any nursing home licenses. Management controls that restrict a provider’s ability
to operate independently have never been applied to assisted living facilities, but state
monitoring was imposed on nursing homes three times in FY 2000-01, and one skilled
nursing facility has been placed in receivership. The Department of Justice issued criminal
complaints against two long-term care facilities from July 1999 through June 2002, and 24
caregivers were charged with criminal resident abuse and or neglect.
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