Surveys, Complaints, and Insufficiencies

481-67.10 through 481-67.13 include several elements of the Assisted Living (AL) survey process including both department and program responsibilities (except 67.12 which relates to adult day services). During this rule review, we’ll focus on what the program is expected to do during the visits.

481-67.10(2) requires that the assisted living program provide all records and areas of the program that are deemed necessary to determine compliance to the surveyor for purposes of conducting the monitoring visits. While this rule is not cited often, it is important to understand that any documentation requested should be provided to the surveyor to allow them to determine compliance. This includes allowing them to tour/observe areas throughout your building which are necessary to carry out the survey process. Another important area to consider within these rules is 481-67.10(3) which discusses using a preponderance of evidence when determining whether a regulatory insufficiency exists. The rule clearly outlines that the surveyor is not expected to witness the event of non-compliance, however, by using investigation techniques the surveyor will determine if there is non-compliance. Surveyors generally use several methods to gather a preponderance of evidence including observations, record reviews, and interviews of tenants, responsible parties and staff.

481-67.11 includes procedures for complaints and program-reported incident report investigations. The important piece of this rule is 67.11(2) which outlines the program’s responsibility to report incidents and complaints. The preferred method of reporting is using the Health Facilities Database, however, reports can also be mailed in, called to the complaint hotline at 1-877-686-0027 or via fax at 515-281-7106. As a reminder, the reporting requirements outline the “most expeditious means” which would likely not be mailing in the information. Additional reporting requirements can be found under 481-67.4.

481-67.13 includes procedures regarding an exit interview, final report, plan of correction, and a monitoring revisit. The surveyor will complete an exit interview with the program either in person or by phone. The exit interview outlines specific concerns identified during the survey process and allows the program two business days from the exit interview to provide additional information to the Department of Inspections, Appeals and Licensing (DIAL). DIAL then has 10 business days from either the end of the monitoring visit or from when the program submits additional information to complete a final report. (Note, despite the rule indicating the report is due within 10 business days, they may be later than this.)

When the program receives the final report and there are regulatory insufficiencies cited, the program must complete a plan of correction. The plan of correction must be returned to DIAL within 10 working days of receiving the report. The following elements must be included in the plan of correction:

• Elements detailing how the program will correct each regulatory insufficiency, including at the system level. (For clarification purposes, the plan of correction should identify how the program corrected the non-compliance for the specific tenant(s)/staff identified and then how it will be corrected in the overall processes.)
• The date the regulatory insufficiency will be corrected, which must be no later than 30 days from the date the final report was received.
• Measures that will be taken to ensure non-compliance does not recur.
• How the program will monitor performance to ensure compliance is achieved.
• Any other required information.

DIAL will review the plan of correction within 10 working days and may request additional information or suggest revisions to the plan of correction. The department may conduct a revisit to ensure that the plan of correction has been successfully implemented. Additional regulatory insufficiencies may be cited during the revisit if identified, however, the surveyors are directed to review evidence from the plan of correction date until the revisit survey is conducted.