Appendix J: Licensing and Inspections

CLA Licensing Inspection Analysis

• Two automated databases exist in the licensing unit offering comprehensive licensing and inspection information for potential management analysis.
• Information outlining several key dates in the inspection process, however, is not updated on a regular basis in either database. As a result, committee staff was only able to analyze inspection process date information for 125 public home inspections and 592 private homes, occurring in calendar years 2000 and 2001, rather than current information for FY 02. Information about providers' plans of correction for rectifying licensing deficiencies is also scant. Regardless, the data available offer a relatively good point-in-time snapshot of the CLA inspection process.
• A separate licensing database, outlining such areas as inspection citations, is more current and includes fiscal year data through FY 02.

Inspection Process -- Public v. Private

• Table J-1 offers a comparison of licensing inspection information between public and private homes covering calendar years 2000 and 2001. State regulations call for CLA licenses to be renewed every year and inspections to occur every two years based on the license expiration date.
• A full two-thirds of public homes were inspected after the license expiration date; the rate for private homes was almost 40 percent.

_ Inspections for half the public homes analyzed occurred at least 12 days after the license expiration date and seven days after the same date for private homes.

_ Of the public homes with late inspections, 75 percent occurred within 36 days of the license expiration date, compared with 51 days for private homes. The longest delay for a licensing inspection was just under three months for public homes, and just under four months for private homes.

• Once an inspection is concluded a "Statement of Citations" (SOCs) is sent to the provider. This process includes the inspector developing the report, forwarding it to the licensing supervisor for review, and sending the report to the provider. This process was consistent for public and private homes, with half the SOCs being sent to the provider more than three weeks after the inspection. State regulations call for such reports to be sent within 15 working days of the inspection.
• A key component of the licensing process is a provider completing a "Plan of Correction" (POC) if deficiencies are found during an inspection. Complete POC information is not formally tracked by the DMR licensing unit in its automated database. The database only tracks the date when the POC was returned by the provider to DMR. Providers have 15 working days from receipt of the statement of citations to submit a plan of correction to DMR.
• Analysis shows half of the POCs from public providers were submitted within 50 days of being sent by DMR, which is almost twice as long as private providers at 28 days. State regulations call for the provider to submit its plan of correction within 15 working days after receiving the citation summary. Although the date the provider receives a statement of citations is not formally tracked, it is doubtful the delay in submitting plans of correction to DMR is due to circumstances outside the provider's control.
• Almost all the plans of correction were accepted by the licensing unit on the initial submittal without the provider having to resubmit a modified POC - 98 percent for public homes and 97 percent for private providers. The unit accepts the plans based on the document submitted by the provider. Until recently, very little on-site follow-up by the licensing unit was conducted to ensure the plans were implemented. The committee was told limited personnel resources made it difficult to do on-site follow-up.
• A new process whereby plans of correction are monitored through on-site visits by DMR was implemented this year. The process uses a three-fold approach, including:

_ licensing inspectors now conduct on-site visits for all inspections resulting in immediate health or safety citations as determined by the licensing unit;

_ inspectors conduct two unannounced follow-up visits per month to ensure providers' recently submitted plans of correction are implemented; and

_ contract monitors use their routine site visits (conducted several times a year per provider) to follow-up on providers' plans of correction resulting from a recent licensing inspection - this decentralized approach has coordination and logistic issues given the monitors are regionally-based and not trained on licensing regulations.

(The program review committee recommends several changes in the process - see full report.)

• Although automated licensing information exists, DMR is not consistently using the information for management analysis purposes. No management reports examining the licensing function from a broad perspective are developed on a consistent basis. Any reports using the licensing data are created on an ad-hoc basis.

Regulation Citations

• Committee staff analyzed the automated licensing database to compare the types of regulations cited during licensing inspections between public and private providers. This was done as another way to gauge whether DMR is applying the same oversight standards among public and private homes during its licensing inspection process.
• Table J-2 shows the top five regulatory categories most frequently cited during licensing inspections for public and private homes for FYs 00-02. There were no differences among public and private homes in the top five regulatory categories cited - each sector had the same top five categories cited for the period analyzed. Note: the regulatory categories in the table encompass a broad range of areas where inspectors can cite providers as being deficient. Specific licensing citations (e.g. excessive water temperature) are made within the context of a broader regulatory category.

Service and Systems Enhancement

• The Service and Systems Enhancement unit exists within the Quality Assurance Division "to examine services and systems through outcome-based measurement processes in order to elicit actions that positively affect people with mental retardation."
• The unit consists of four facilities inspectors (including a nurse), two nurse coordinators, and one supervisor.
• In 1998, DMR required the Quality Assurance Division to replace the previous individual professional review/utilization review process (IPR/UR) with a new process called "quality reviews." The IPR/UR process was conducted by DMR for Intermediate Care Facilities for Mentally Retarded in response to federal Medicaid requirements. The reviews were used to help ensure clients were properly placed and receiving appropriate services.
• When DMR eliminated its ICFs/MR in the community by changing them to Home and Community Based Waiver sites, the federal requirement for the IPR/UR review was also eliminated. The federal reimbursement for that type of review is no longer available.
• The current quality review process focuses primarily on clients at DMR regional centers. Several reviews of individuals at day programs and respite centers also take place.
• In FY 01, the unit conducted 34 reviews involving 188 clients. Table J-3 shows the distribution of reviews. The reviews covered various areas of a client's program and residence. The table shows close to 80 percent of all individuals reviewed by the Service and Systems Enhancement unit inspectors resided in DMR's regional centers, which are designated ICFs/MR.

• The process uses formalized guidelines to evaluate client safety and health, rights and protections, and individual supports and services. A sample of half the facility's residents is chosen for review. All reviews are announced. The reviews result in a multi-page narrative "on the status and outcomes for individual and service system findings." A voluntary feedback questionnaire is also given to providers.
• The quality review process does not produce a statement of deficiencies following a review, and no corrective action plans are required from providers. The reports are sent to DMR regional managers for "consideration in enhancing quality of services." There is no formal implementation process of the outcomes of the quality reviews conducted by the Service and Systems unit.
• The Department of Public Health currently conducts health and safety inspections of DMR's ICFs/MR facilities, including regional centers. The reviews are conducted by a team of DPH inspectors over the course of several days and follow a scripted process. Inspection reports outlining deficiencies are sent to the provider, with summaries sent to the DMR central office. The provider is required to submit a plan of correction to DPH and is responsible for implementing the corrective actions outlined in the plan.
• The committee believes the "quality review" process duplicates the effort of DPH's formal inspections of ICF residences, namely regional centers and Southbury Training School. The DMR process does not result in concrete, measurable outcomes, given no citations are issued or plans of correction developed.
• The program review committee believes the health and safety of DMR's clients would be better served if the inspectors from the department's SSE unit were integrated with the licensing and inspection unit within the Division of Quality Assurance. More inspectors would then be available to the licensing unit to help ensure the health and safety of clients living in community living arrangements. Making the transfer would provide the necessary staff resources to the licensing unit to conduct on-site follow-up visits to observe whether providers are fully implementing their plans of correction - a process not currently done by the unit for every plan of correction. The transfer would not affect the department's requirement to continuing auditing Southbury Training School as mandated.
• Considerations
• The program review committee also considered moving the licensing and inspection function to the Department of Public Health with attendant staff. DPH is responsible for inspecting the ICFs/MR for federal certification under Medicare/Medicaid, as described above. Given the enhancements to the licensing and inspection function recommended by the committee in the full report, such a move was not considered necessary at this time.