1. Assisted Living Forum “State of Assisted Living” September 9, 2008

2. New DQA Assisted Living Boundaries – effective 1-1-2007

3. Where are we going? 2008 - 2009

4. Continue and Expand Collaborations

5. Using data to effect positive change

6. Deploying Resources to Effect Positive Change

7. Proactive Compliance

8. Implement HFS 83

9. New facility video on Web

10. Medication Management Initiative

11. Make more information available on the web – statistics, trends, etc.

12. Support and Encourage Innovation

13. To have the best staff with the tools and training to do their job

14. Trends & Statistics

15. Assisted Living Trend in # of Facilities

16. Assisted Living Trend in capacity for residents

17. RCACs Certified vs. Registered

18. AL vs. LTC Trend in number of facilities

19. AL vs. LTC Trend in capacity for residents

21. Family Care Impact on AL Industry Family Care counties Rest of State 2000 Capacity4.3 beds/1003.2 beds/100 2006 Capacity5.9 beds/1003.7 beds/100 Average increase 36.3%21.8%  Projections indicate 62% of the state will be covered by Family Care by June, 2009

22. Relocations 540 of 1412 residents of ICF/MRs have been moved: –449 moved into BAL regulated facilities 341 into 3-4 bed AFHs 108 into 5-8 bed CBRFs –872 residents are left to be moved 1,282 nursing home relocations have been completed (majority to BAL regulated facilities) –905 elderly residents –379 individuals with developmental disabilities

23. Nursing Home Diversions 300 slots Majority to BAL regulated facilities

24. Population Served 4215 assisted living residents with Long Term Care Functional Screen data: –34% have diagnosis of Alzheimer’s disease –92.6% need assistance with bathing –70.5% need assistance with dressing –33.4% need assistance with eating –49.9% need assistance with toileting –18.3% require a behavior intervention –3,460 MH diagnoses (depression, anxiety, bipolor, schizophrenia) –56.7% use a walker –26.7% use a wheelchair or scooter These residents are publicly funded under MA Waivers, Family Care, or Pace/Partnership to live in AFHs, CBRFs, and RCACs

25. Waiting Lists As of May 31, 2007 – 11,625 on the COP/Waiver waiting list With entitlement, how many of these will be living in BAL regulated facilities….?

26. Publicly Funded Clients in AL * Estimated publicly funded clients in occupied AL beds

27. Public Funding becoming more influential driver…..

28. New AL vs. Closed AL

29. Why Facilities Closed CY 2007

30. Why Facilities Closed 6 months June 30, 2008

31. Post Survey Questionnaire 2007 - 161 respondents (37% of total) Satisfaction with survey tasks 97.3% On Site - 4.57 –Knowledgeable - 4.57 –Professional - 4.76 –Respectful - 4.71 SOD – 4.21 (1 = strongly disagree, 5 = strongly agree)

32. Survey Results 2004 2006 2005 2007

33. Survey Results Jan-June 2008

34. AL Citations Issued

35. Top CBRF cites comparison: 2006-2007

38. Tenant Rights 89.34(16) Services 89.23(2)(c)

41. Surveys with Enforcement

43. Surveys with Enforcement (545) CY 2007

44. Surveys with Enforcement (241) June 30, 2008

45. % of Facilities vs. % Enforcement Surveys

47. % of Beds vs. % Enforcement Surveys

49. Sanctions Imposed (1,077) CY 2007

50. Sanctions Imposed (486) June 30, 2008

51. Type of Sanctions CY 2007

52. Type of Sanctions June 30, 2008

55. Forfeiture Assessments

57. Impending Revocations

58. Impending Revocations 2007

59. Impending Revocations June 30, 2008

60. Revocations

62. 35% Forfeiture Reduction

63. Enforcement Action Appealed CY 2005CY 2006 CY 2007

64. Enforcement Action Appealed 6 months, June 30, 2008

65. Complaints Received

66. Complaints vs. Growth

68. Complaints Received CY 2007

69. Complaints Received June 30, 2008

70. % of Facilities vs. Complaints Received

71. % of Facilities vs. % Complaints received

72. % of Beds vs. Complaints Received

73. % of Beds vs. % Complaints received

74. Source of Complaint CY 2007

75. Ranking – Subject areas complaint investigations 200220032004200520062007 Program Services 121144 Medications 455233 Resident Rights 244311 Administration 312422 Res. Behavior/ Facility practice 8335510 Nutrition & Food 667668 Staff Adequacy 798777 Abuse 12 11895

76. Source% rec. & invest.% substantiated Anonymous2329 Public Official2453 Relative/Guardian1941 Current Employee0542 Former Employee1047 Advocate0651 Citizen0528 Medical0534 Resident0223 100%41% Source of Complaint vs Substantiation CY 2007

79. Self Reports CY 2007

82. Facilities Qualifying for Abbreviated Surveys – June 2008 Adult Day Care61.3% Adult Family Homes42.7% Community Based Residential Facility38.9% Residential Care Apartment Complex50.4% Statewide42.2%

83. Facilities Qualifying for an Abbreviated Survey

84. Stories …. (examples of enforcement actions)

85. IN SUMMARY…. Growth continues across all Assisted Living providers although new licenses issued appears to be declining somewhat. More RCAC growth with certified as the gap with registered continues to widen. ICF/MR rebalancing, NH relocation initiative and Family Care expansion having direct impact on AL growth. AL licensed beds projected to exceed NH & ICF/MR licensed beds by end of 2008 or early 2009 In addition to overall growth, there is significant turnover with increases in voluntary closures, and Change of Ownership (CHOW) Fit and Qualified policy having a positive effect with increase of license denials and withdrawn applications

86. IN SUMMARY…. Citations per survey decreased slightly. Top citations and type of sanctions more reflective of deployment of resources to facilities with non-compliance concerns or allegations BAL continues to refine directed plans of correction to help facilities achieve and sustain compliance. When this does not work, progressive, punitive enforcement usually does Compared to number of facilities and beds, CBRFs make up a significantly high proportion of enforcement Compared to number of beds, AFHs make up a significantly high proportion of enforcement although it did decrease from CY 2007

87. IN SUMMARY…. Complaints projected to increase slightly Compared to number of facilities and beds, CBRFs make up a significantly high proportion of complaints Compared to number of beds AFHs make up a significantly high proportion of complaints and appears to be increasing

88. IN SUMMARY…. Self reports received is projected to increase again, but when investigated rarely result in deficiencies. BAL not meeting the workload with overall growth in industry, more complex investigations, increased enforcement and self reports.

89. IN SUMMARY…. The “new resident” is impacting the regulatory activity Majority of assisted living in Wisconsin is very good and continues to improve Collaboration continues to move the “bell curve to the right” More facilities qualifying for abbreviated surveys For CY 2007 only 15 % of facilities make up 100% of the complaints and enforcement action.

90. Thank You! Moving the Bell Curve to the Right...