1. Health and Wellness for all Arizonans Maintaining Compliance in Residential Facilities

2. Health and Wellness for all Arizonans Arizona Department of Health Services Cara Christ M.D., Director Division of Public Health Licensing Bureau of Residential Facilities Licensing Diane Eckles, Bureau Chief

3. Health and Wellness for all Arizonans Office Locations and Phone Numbers Phoenix: 150 N. 18 th Ave., Suite 420 602-364-2639FAX: 602-324-5872 Tucson: 400 W. Congress St., Suite 116 520-628-6965FAX: 520-628-6991 Website: http://azdhs.gov/licensing/residential-facilities/index.php http://azdhs.gov/licensing/residential-facilities/index.php Email: Residential.Licensing@azdhs.govResidential.Licensing@azdhs.gov

4. Health and Wellness for all Arizonans Bureau of Residential Facilities Licensing (BRFL) Licenses, regulates, and provides training to Residential Healthcare Facilities; including Assisted Living Centers, Assisted Living Homes, Adult Foster Care Homes, Behavioral Health Residential Facilities, Adult Day Health Care Facilities, Behavioral Health Respite Homes, and Adult Behavioral Health Therapeutic Homes based on Arizona’s Rules and Statutes Our goal is COMPLIANCE – we want to help you to be in compliance with the applicable Rules and Statutes for your facility It is your responsibility to ensure you are aware of the rules as they apply to your facility

5. Health and Wellness for all Arizonans Applicable Rules and Statutes Licensing of Residential Facilities is governed by the Arizona Revised Statutes (“A.R.S.”), primarily Title 36: Public Health and Safety, Chapter 4: Health Care InstitutionsTitle 36: Public Health and Safety, Chapter 4: Health Care Institutions Reference to a statute generally uses this format: A.R.S. § 36-401.A.1.A.R.S. § 36-401.A.1. or A.R.S. § 36-401(A)(1)A.R.S. § 36-401(A)(1) Reference to a rule is generally in this format: – Title 9, Chapter 10, Article 8 (specific subclass), Rule Number 803.A.3.a – Example of an Assisted Living Rule R9-10-803.A.3.a Statutes are law that authorize the Department to adopt Rules which are specific to each facility type

6. Health and Wellness for all Arizonans Rules Governing Residential Facilities  Article 1: General  Article 7: Behavioral Health Residential Facilities  Article 8: Assisted Living Facilities  Article 11: Adult Day Health Care Facilities  Article 16: Behavioral Health Respite Homes  Article 18: Adult Behavioral Health Therapeutic Homes You can find the most up-to-date copy of the rules at our website: http://www.azdhs.gov/licensing/residential- facilities/index.php#providers-home http://www.azdhs.gov/licensing/residential- facilities/index.php#providers-home

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9. The Survey Process Compliance–are you ready for inspection? Most inspections are unannounced Length of inspection varies depending on: – Size of facility – Completeness and organization of records – Compliance with the rules Surveys follow current rules, statutes, and the facility P&P’s

10. Health and Wellness for all Arizonans The Survey Process Surveys will be conducted based on the outcomes and the facility’s Policies & Procedures (P&Ps) The rules require facilities to establish, document, and implement Policies and Procedures (P&Ps) to protect the health and safety of a resident Know your scope of services

11. Health and Wellness for all Arizonans Types of Surveys There are five main kinds of surveys that surveyors will conduct: Initials Change of Ownership (CHOWs) Compliance Amends Complaints

12. Health and Wellness for all Arizonans Licensure Period Your licensure period runs for 12 months. – Not always going to be January 1-December 31 – A surveyor can show up at ANY point within your licensing period for the compliance survey – Compliance survey may not be the same month year after year

13. Health and Wellness for all Arizonans CHOWs CHOW = Change of Ownership If you are purchasing or leasing a facility that is already licensed as a Residential Facility, this is referred to as a “CHOW” A.R.S. 36-422.D: the current licensee must notify the Department in writing at least 30 days prior to the planned change of ownership and ensure services are not interrupted A.R.S. 36-422.D The new owner may not begin operating the facility until the Department issues a license. If the facility receives an inspection, it is treated similar to an Initial

14. Health and Wellness for all Arizonans Compliance Inspection is conducted once per licensing period The Surveyor will check for health and safety issues and outcomes The Surveyor will also conduct a tour of the facility, review the facility’s P&Ps, resident records, employee records, and facility records The Surveyor will also conduct interviews, as appropriate, during the inspection You are encouraged to accompany the Surveyor during the inspection process and to ask questions Please take notes during the survey; the Surveyor cannot give you a copy of his/her notes If you’re deficiency free – kudos

15. Health and Wellness for all Arizonans Amend Anything that changes the existing license – Bed Increase or Decrease – Adding a service such as: Personal Care for BH Behavioral Health Services for AL Outdoor Behavioral Health Program for BH Changing the level of care Submit a written request to make a change Surveyor will ensure compliance before the facility is allowed to make a change

16. Health and Wellness for all Arizonans Complaints Sometimes, complaints are received on your facilities Don’t take it personally All complaints are confidential, surveyors do not release the complainant information Surveyors will look to see WHAT happened and deficiencies will be cited if there was a failure on the facility’s behalf

17. Health and Wellness for all Arizonans All Surveys The surveyor will always present a “Notice of Inspection Rights”, often referred to as an “Entrance Letter” Anyone in the facility can sign it, Surveyors don’t have to wait for the manager or administrator to sign Read it carefully and ask the surveyor if you have any questions or concerns You will be asked to sign it, but if you don’t, the survey will continue to be conducted

18. Health and Wellness for all Arizonans Statement of Deficiencies (“SOD”) After the inspection is compete, the Surveyor will conduct an exit interview with the manager/administrator or designee to inform them of findings found – Department will not give a list of deficiencies Findings may or may not mean deficiencies – TA Discussion Rosters will not be sent – need systemic fix & HIPAA If you have no deficiencies: – A “No-Deficiency” Statement of Deficiencies is written If you have deficiencies: – Surveyor & Team Lead review data to determine citations – A Statement of Deficiencies (SOD) is mailed – An acceptable Plan of Correction is required(POC)

19. Health and Wellness for all Arizonans Plan of Correction (“POC”) Required from the facility after a facility received a SOD with deficiencies Please read the cover letter that comes with the SOD carefully. It gives you information and deadlines that apply to your situation You will need to write a POC for each citation on the space provided on your SOD or attach the POC on a separate paper

20. Health and Wellness for all Arizonans Plan of Correction (“POC”) The POC must outline the specific steps taken to correct each deficiency noted, and must include the following: 1.How the deficiency is to be corrected, on both a temporary and permanent basis 2.The date the correction will be completed 3.The name, title, and/or position of the person responsible for implementing the corrective action 4.A description of the monitoring system you will use to prevent the deficiency from recurring 5.The signature, title, and date signed of the person responsible for the POC on the first page of the SOD

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22. Plan of Correction (“POC”) Please follow the steps stated on the cover letter to complete the POC process. Call your surveyor if you have questions You can find a copy of the SOD cover letter with a sample POC on our website: http://azdhs.gov/licensing/residential- facilities/index.php http://azdhs.gov/licensing/residential- facilities/index.php

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26. Plan of Correction (“POC”) Return the signed SOD with the POC to the Department. Include any supporting documentation, pictures, etc., as proof that you have made the necessary corrections Keep a copy for your records. You must make the SOD and POC available to the public Late POC’s – Get them in on time! – Late letters will be sent and could lead to further enforcement action – No extensions 26

27. Health and Wellness for all Arizonans Plan of Correction (“POC”) Your surveyor will review your POC Acceptable POC’s – If it is acceptable, the surveyor will recommend closing the survey Unacceptable POC’s – You will receive a letter detailing what is missing – Read the letter; if it was unacceptable, it means the POC didn’t meet one of the requirements in the SOD letter – Call your surveyor if you aren’t sure what it means

28. Health and Wellness for all Arizonans Plan of Correction (“POC”) Depending on the circumstances, the surveyor may do an onsite follow-up inspection to ensure all deficiencies are corrected before closing the inspection Reminder: Your survey results and POC is public record 28

29. Health and Wellness for all Arizonans POC vs. IDR If you wish to use the Informal Dispute Resolution (“IDR”) process to have deficiencies changed or removed, your IDR must be separate from your POC and sent to Diane Eckles, Bureau Chief The POC must include all deficiencies, even those for which you are filing an IDR A POC which includes language that disputes that the deficiency occurred, or does not address a deficiency will be returned to you as unacceptable

30. Health and Wellness for all Arizonans Informal Dispute Resolution Referred to as an IDR The IDR process is described on our website: http://azdhs.gov/als/residential/documents/infor mal-dispute-resolution-process.pdf http://azdhs.gov/als/residential/documents/infor mal-dispute-resolution-process.pdf The purpose of an IDR is to show the facility was in compliance at the time of inspection It is not a guarantee a deficiency will be removed just because you disagree It has to be legitimate and specific to the citation

31. Health and Wellness for all Arizonans Top Deficiencies Top 10 deficiencies 07/01/2014 through 04/30/2015 for Behavioral Health Residential Facilities 1.R9-10-707.A.12.a-b: Admission; Assessment 2.R9-10-722.B.5.a: Physical Plant Standards 3.R9-10-707.A.5: Admission; Assessment 4.R9-10-708.A.5: Treatment Plan 5.R9-10-720.B.4: Emergency and Safety Standards 6.R9-10-708.A.4.c: Treatment Plan 7.R9-10-707.A.7.a: Admission; Assessment 8.R9-10-708.A.2.b: Treatment Plan 9.R9-10-721.A.10: Environmental Standards 10.R9-10-722.B.8.g.ii.(2): Physical Plant Standards

32. Health and Wellness for all Arizonans Top Deficiencies Top 10 deficiencies 07/01/2014 through 04/30/2015 for Assisted Living Facilities 1.R9-10-816.B.3.b: Medication Services 2.R9-10-819.A.11: Environmental Standards 3.R9-10-807.B.1.a-b: Residency and Residency Agreements 4.R9-10-818.A.4: Emergency and Safety Standards 5.R9-10-811.C.17: Medical Records 6.R9-10-819.A.1.b: Environmental Standards 7.R9-10-816.F.1: Medication Services 8.R9-10-818.F.4.a.i-iv: Emergency and Safety Standards 9.R9-10-808.C.1.g: Service Plans 10.R9-10-806.A.7.a-b: Personnel

33. Health and Wellness for all Arizonans Treatment Plans vs Service Plans Treatment Plans = Article 7, Behavioral Health Residential Facilities – Article 1 definition: “Treatment plan” means a description of the specific physical health services or behavioral health services that a health care institution anticipates providing to a patient Service Plans = Article 8, Assisted Living Facilities – Article 8 definition: “Service plan” means a written description of a resident’s need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident

34. Health and Wellness for all Arizonans Treatment Plans R9-10-708 - An administrator shall ensure a treatment plan is: Developed and implemented for each resident that is based on the medical history and physical examination or nursing assessment and the behavioral health assessment and on-going changes to the behavioral health assessment Completed by a BHP or a BHT receiving clinical oversight (BHPP’s cannot develop a treatment plan) Completed before the resident receives behavioral health services or within 48 hours after the assessment is completed Treatment plans are updated according to the review date or when the assessment changes SPECIFIC TO THE RESIDENT! NO TWO RESIDENTS ARE ALIKE

35. Health and Wellness for all Arizonans Resident is admitted. Behavioral health assessment is completed. BHP reviews assessment. Physical health & ancillary services begin. Treatment plan completed BHP reviews treatment plan. Within 48 hours of admission & filed in the medical record Within 24 hours of completion. Within 48 hours of completion of assessment & filed in the medical record. Within 24 hours of completion of treatment plan. Behavioral health services begin

36. Health and Wellness for all Arizonans Service Plans R9-10-808, R9-10-814.F, and R9-10-815.C: Lists service plan requirements depending on resident’s level of care Key item: Amount, type, and frequency of services! Developed with assistance and review from the resident or resident’s representative, the manager, and individual requested by the resident or resident’s representative If a resident requires intermittent nursing services or medication administration, must be reviewed by a nurse or medical practitioner Completed no later than 14 calendar days after the resident’s date of acceptance Updated no later than 14 calendar days after a significant change in the resident’s physical, cognitive, or functional condition AND – Once every 12 months for a resident receiving supervisory care services – Once every 6 months for a resident receiving personal care services – Once every 3 months for a resident receiving directed care services SPECIFIC TO THE RESIDENT! NO TWO RESIDENTS ARE ALIKE

37. Health and Wellness for all Arizonans Medication Services Behavioral Health Residential: R9-10-718 Assisted Living Facilities: R9-10-816 Facilities must have policies and procedures!

38. Health and Wellness for all Arizonans Self-Administration of Medication R9-10-101.184 Definition: “Self-Administration of Medication” means a patient having access to and control of the patient’s medication and may include the patient receiving limited support while taking the medication – Facility does not lock or store medication; resident must have access at all times – Limited support may include: General reminders to take medication or asking if resident had taken medications that day Retrieving medication containers for the resident or opening the medication container, if the resident is physically unable and requests the assistance

39. Health and Wellness for all Arizonans Assistance in the Self-Administration of Medication R9-10-101.17 Definition: “Assistance in the self-administration of medication” means restricting a patient’s access to the patient’s medication and providing support to the patient while the patient takes the medication to ensure the medication is taken as ordered

40. Health and Wellness for all Arizonans Assistance in the Self-Administration of Medication continued The following assistance is provided to a resident: a.A reminder when it is time to take the medication; b.Opening the medication container for the resident; c.Observing the resident while the resident removes the medication from the container; d.Verifying that the medication is taken as ordered by the resident’s medical practitioner by confirming that: i.The resident taking the medication is the individual stated on the medication container label, ii.The resident is taking the dosage of the medication stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label, and iii.The resident is taking the medication at the time stated on the medication container label or according to an order from a medical practitioner dated later than the date on the medication container label; or e.Observing the resident while the resident takes the medication;

41. Health and Wellness for all Arizonans Medication Administration R9-10-101.120 Definition: “Medication Administration” means restricting a patient’s access to the patient’s medication and providing the medication to the patient or applying the medication to the patient’s body, as ordered by a medical practitioner

42. Health and Wellness for all Arizonans Medication Administration continued Medication must be stored by the facility Policies and procedures must exist Administered to a resident: – Is administered in compliance with a medication order, and – Is documented in the resident’s medical record

43. Health and Wellness for all Arizonans Medication Storage BH Residential: R9-10-718.E AL Facilities: R9-10-816.F Medications stored a the facility: Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage Medication is stored according to the instructions on the medication container Policies and procedures must be established, documented, and implemented: – Receiving, storing, inventorying, tracking, dispensing, and discarding medication, including expired medication; – Discarding or returning prepackaged and sample medication to the manufacturer if the manufacturer requests the discard or return of the medication; – A medication recall and notification of the residents who received recalled medication; and – Storing, inventorying, and dispensing controlled substances

44. Health and Wellness for all Arizonans Drug and Toxicology Reference Guides R9-10-718.D (BH Residential) & R9-10-816.D (AL Facilities) 1. A current drug reference guide is available for use by personnel members, and 2. A current toxicology reference guide is available for use by personnel members – These references can be “online,” as long as they are available at all times. – A common toxicology reference is TOXNET, which can be found at: http://toxnet.nlm.nih.gov/http://toxnet.nlm.nih.gov/ – Current means the publication has not been updated and is not out-of-date (i.e. – 1982 PDR)

45. Health and Wellness for all Arizonans Renewal Application The Department mails renewal reminder postcards as a courtesy, but you are responsible for ensuring that your renewal application is submitted on time When a completed renewal application and all fees are received, the Department will mail you your new license. Hang the original license on the wall 45

46. Health and Wellness for all Arizonans Compliance Team Not a comprehensive list, but common items referred for Enforcement Action: – Late applications – Repeat/uncorrected deficiencies – Fingerprinting – Personnel issues (CPR/FA, training) – Residents left alone

47. Health and Wellness for all Arizonans Late Applications Renewal applications are due to the Bureau no later than 60 days prior to the expiration date on the license An application received 59 or fewer days prior to the license expiration date will result in the assessment of a civil penalty of $250.00 for a first offense Subsequent offenses will result in higher penalties

48. Health and Wellness for all Arizonans Late Applications If an application is not received prior to the expiration date of the license, the facility may be considered closed If such a facility is still providing services, enforcement action may be taken, as the facility is considered to be providing unlicensed care

49. Health and Wellness for all Arizonans Repeat/Uncorrected Deficiencies After any survey and deficiencies are cited, a plan of correction is expected Once the plan of correction is received, reviewed, and accepted, the deficiency should NOT be found at or during the next inspection If it is, it is a repeat or uncorrected deficiency

50. Health and Wellness for all Arizonans Fingerprinting Fingerprint Statutes – A.R.S. 36-411 – A.R.S. 36-425.03 (Specific to Behavioral Health Residential Facilities providing services to children) Direct care staff in all facilities must have fingerprint clearance – BH residential facilities who serve children have a more restrictive requirement

51. Health and Wellness for all Arizonans Personnel Issues CPR/First Aid Training: No staff onsite have current CPR/First Aid training Non-caregivers: For Assisted Living and BH residential authorized to provide Personal Care services – Leaving a resident with a volunteer, staff, or individual who does not have Caregiver training approved through the NCIA Board

52. Health and Wellness for all Arizonans Residents left alone Believe it or not, it has happened Residents left alone with no supervision Going around the corner to a next door house or facility doesn’t count as being on premises All subclasses require AT LEAST one personnel member present at the facility when there is a resident – Many facilities require personnel to be awake, some don’t, check your rules!

53. Health and Wellness for all Arizonans QUESTIONS? Phoenix office: 150 N. 18th Ave., Suite 420 602-364-2639FAX: 602-324-5872 Tucson office: 400 W. Congress St., Suite 116 520-628-6965FAX: 520-628-6991 Website: http://azdhs.gov/licensing/residential-facilities/index.php http://azdhs.gov/licensing/residential-facilities/index.php Email: Residential.Licensing@azdhs.govResidential.Licensing@azdhs.gov

54. Health and Wellness for all Arizonans Thank you!