Annual On-Site Review and Complaint Investigation Procedures

Section 295 Section 295.1070  Annual On-Site Review and Complaint Investigation Procedures a) The Department will conduct an annual unannounced on-site visit at each assisted living and shared housing establishment to determine compliance with the applicable licensure requirements and standards as set forth in the Act and this Part. Additional visits may be conducted without prior notice to the assisted living or shared housing establishment. (Section 110(a) of the Act) b)         The purpose of the annual on-site review shall be to ensure establishments' compliance with this Part and to assist the licensee in meeting the requirements of this Part and providing quality services to the consumer.  The visit shall focus on solving resident issues and concerns, and the quality improvement process implemented by the establishment to address resident issues. (Section 30(a) of the Act) The on-site review shall be conducted in a collaborative manner, with the Department and the establishment focused on meeting the needs of the residents. c)         The review shall address the following issues: 1)         Assessment, service plan and services provided to ensure that resident needs are met; 2)         Staff sufficient in numbers and with appropriate skill, education and training to provide services required by the resident population; 3)         Compliance with the Health Care Worker Background Check Act and the Essential Support Person Act; 4)         Compliance with service delivery contracts and lease agreements; 5)         Grievance procedures; 6)         Service plan, negotiated risk, and protection of individual rights and resident's involvement in directing their own care; 7)         Quality improvement policies and procedures to determine whether an effective procedure is in place.  Quality improvement policies shall not be used as the sole criterion for issuance of a violation; 8)         Whether an annual resident satisfaction survey has been conducted; 9)         Compliance with physical plant, health and sanitation, and food preparation requirements as set forth in this Part; 10)         Any complaints not reviewed through an on-site review; and 11)         Incident and accident reports that are required to be submitted to the Department. d)         An establishment shall not restrict or hamper access by Department staff to the building, residents or designated records required to conduct routine or periodic review or investigations.  A resident may limit access to their private dwelling space to reviewers, except if suspected violations exist that may pose a threat to the resident's or others' health, safety or well-being.  A resident may also elect to limit access to themselves and their records, except as required as a condition of payment for publicly funded housing and/or services. e)         When the Department identifies a technical infraction during an on-site inspection, the Department representative shall engage the establishment staff in a consultative conference.  If the establishment resolves the technical infraction prior to the end of the on-site inspection, no violation shall be deemed to exist and no violation shall be reported. The Department may recommend methods of addressing the technical infraction. f)         Prior to concluding the on-site inspection, the Department representative will meet with the manager regarding any identified technical infraction.  The Department will allow the establishment an opportunity to discuss the technical infraction and to present any evidence that indicates that the technical infraction did not exist or evidence related to the level of the violation. g)         The Department will provide the establishment with a written statement of findings and violations via U.S. mail or other electronic means within 10 business days after exiting the on-site inspection. h)         The establishment shall file a statement of correction within 15 days after receipt of the statement of findings and violations.  The statement of correction shall describe the action taken by the establishment to address the violation.  Each statement of correction shall be based on an assessment by the establishment of the conditions or occurrences that are the basis for the violation and evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.  Evidence of such assessment and evaluation shall be maintained by the establishment.  Each statement of correction shall include: 1)         A description of the specific corrective action the facility is taking, or plans to take, to abate, eliminate, or correct the violation cited in the notice; 2)         A description of the steps that will be taken to avoid future occurrences of the same and similar violations; and 3)         A specific date by which the corrective action will be completed. i)          The establishment may also submit a statement of dispute regarding any of the alleged violations within 15 days after receiving the statement of findings and violations. The Department shall review all statements of dispute submitted prior to making its final determination that a violation exists or of the level of the violation.  If the Department does not make a change to the statement of violations based upon the statement of dispute, it shall provide a brief justification of its determination in writing and the establishment shall submit a statement of correction pursuant to subsections (j) through (m). j)          The Department will review each statement of correction to ensure it provides for the abatement, elimination, or correction of the finding or violation.  The Department will reject a submitted plan if it finds any of the following deficiencies: 1)         The plan does not appear to address the conditions or occurrences that are the basis of the finding or violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences. 2)         The plan is not specific enough to indicate the actual actions the establishment will be taking to abate, eliminate, or correct the finding or violation. 3)         The plan does not provide for measures that will abate or eliminate or correct the finding or violation. 4)         The plan does not provide steps that will avoid future occurrences of the same and similar findings or violations. 5)         The plan does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the residents, and the extent and complexity of the corrective action. k)         When the Department rejects a submitted statement of correction, it will notify the establishment in writing and will specify the reason for the rejection.  The establishment must submit an acceptable plan of correction within 30 days after receiving the notice of rejection.  Failure to submit a revised acceptable plan of correction may result in suspension or loss of license under Section 295.1060(d). l)          The notice of findings shall include the reason for the determination and a statement of the right to appeal the determination pursuant to the Department's Rules of Practice and Procedure in Administrative Hearings. m)        Whenever there is a revisit for a Type 1 violation or a pervasive pattern of Type 2 violations, the Department will conduct the on-site revisit within 30 days after the Department's receipt of the statement of correction or within 30 days after the corrective action is completed to confirm that the establishment has carried out the corrective action.  Nothing prohibits the Department from conducting a revisit at any time.