AN EXPOSITION OF IRREGULARITIES IN RESIDENTIAL CARE
FACILITIES FOR THE ELDERLY (RCFE) IN
SAN DIEGO AND IMPERIAL COUNTIES
_______________
A Thesis
Presented to the
Faculty of
San Diego State University
_______________
In Partial Fulfillment
of the Requirements for the Degree
Master of Science
in
Gerontology
_______________
by
Christine M. Murphy
Spring 2011
iii
Copyright © 2011
by
Christine M. Murphy
All Rights Reserved
iv
DEDICATION
This exposition is dedicated to Alvada S. & Weston F. Maughan. It was by and
through your individual journeys to transcending this plane, that I discovered my passion.
This work is yours.
v
It is not only for what we do that we are held responsible,
but also for what we do not do.
–Moliere
vi
ABSTRACT OF THE THESIS
An Exposition of Irregularities In Residential Care Facilities
For The Elderly (RCFE) in San Diego and Imperial Counties
by
Christine M. Murphy
Master of Science in Gerontology
San Diego State University, 2011
Purpose: The purpose of this study was to describe and characterize irregular
administrative and enforcement practices and patterns of regulation by Community Care
Licensing Division (CCL), Department of Social Services (DSS) of Residential Care
Facilities for the Elderly (RCFEs). The study was a ten-year retrospective descriptive study
reviewing 50% (348 files) of the population of RCFEs licensed in San Diego and Imperial
counties.
Design and Methods: This is a ten-year retrospective descriptive study, which
reviewed the public files of 348 RCFEs licensed to provide care and supervision pursuant to
Title 22 of California’s Civil Code. Files obtained through California Public Records Act
requests were reviewed in detail, and data corresponding to defined parameters was obtained.
Data was analyzed in aggregate, as well as by facility size: each facility was categorized by
bed capacity and placed into one of five strata (e.g. Strata 1 = 1 to 6 bed facilities.)
Individual databases were maintained for Facility Characteristics (ownership, business-model
type, Facility Licenses), Staffing, Finances and Enforcement variables (citations by type, by
inspector). Appendices to the study provide detail of all collected variables.
Findings: In addition to demographic characteristics, this study found irregularities
of incorrect licenses; staffing practices by total facility staffing, the role the regulations play
in understaffed RCFEs. Financial characteristics including average room rental rates,
average monthly and daily food allowances per resident, and average monthly profits
allowed analysis of operational costs, raising questions about abnormally-low food budgets,
and over-industry profit margins. Irregularities in Enforcement findings include the Top Ten
regulations cited over the retrospective 10-year time period, irregular LPA patterns of
citation emerge, findings that 25% of Civil Penalties have been collected. The data also
shows a widespread pattern of missing and incomplete data in nearly every category of data
in the file.
Implications: The findings imply that CCL is either incompetent, or that the
regulations are so imprecise as to prevent meaningful enforcement of the law. Patterns of
missing and incomplete data skew the public file in favor of the Licensee (RCFE owners)
and may contribute to information asymmetry by preventing the consumer of long-term care
from accessing a complete public record on individual RCFE performance. The findings
further imply that CCL has ignored the public trust to provide meaningful and complete
documentation in the public file, and has contributed to creating an information gap being
filled with provider-generated information about assisted living, and residential care facilities
for the elderly.
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TABLE OF CONTENTS
PAGE
ABSTRACT ............................................................................................................................. vi
LIST OF TABLES .................................................................................................................. xii
LIST OF FIGURES ............................................................................................................... xiv
GLOSSARY ............................................................................................................................xv
ACKNOWLEDGEMENTS ................................................................................................... xvi
CHAPTER
1
INTRODUCTION .........................................................................................................1
Public File as Proxy .................................................................................................2
Study Design ............................................................................................................2
Literature Sources ....................................................................................................3
Nursing Home Data ...........................................................................................3
Child Care Facilities ..........................................................................................3
Terminology .............................................................................................................4
Title 22 ...............................................................................................................5
LPAs ..................................................................................................................6
Resident Characteristics .....................................................................................6
Licensing ............................................................................................................7
Non-Medical Model Providing Medical Services .............................................8
Enforcement .....................................................................................................10
The Continuum of Compliance and Enforcement ...........................................10
viii
Consumer Advocates for RCFE (Residential Care Facilities for the
Elderly) Reform (CARR) .......................................................................................10
2
LITERATURE REVIEW ............................................................................................13
Facility Size and License .......................................................................................13
Size and Ownership .........................................................................................14
Licensing ..........................................................................................................15
Staff ........................................................................................................................16
Adequate Staffing versus Staff-to-Resident Ratios .........................................16
Ancillary Staffing.............................................................................................17
Caregivers and Language .................................................................................17
Self-Reported Staffing Levels..........................................................................18
Finances .................................................................................................................18
Monthly Revenues and Per Day Rates.............................................................18
Monthly and Daily Food Allowance................................................................19
Profits ...............................................................................................................20
Enforcement ...........................................................................................................21
LPAs Role as a Tool for Enforcement .............................................................22
Citation Trends.................................................................................................24
Under Citing.....................................................................................................24
Citation Gaps ...................................................................................................24
Civil Penalties ..................................................................................................25
Reliability of the Public Record.............................................................................25
3
METHODS ..................................................................................................................28
Sample....................................................................................................................28
ix
California Public Records Act (CPRA) Request .............................................30
CCLD Protocol ................................................................................................30
File Composition..............................................................................................31
Collection Method .................................................................................................31
File Information by Tab ...................................................................................31
Facility List ......................................................................................................32
Financial Information.......................................................................................32
Staff Information..............................................................................................34
Facility Evaluation and Complaint Information ..............................................34
4
RESULTS ....................................................................................................................38
Facility Characteristics...........................................................................................38
Growth in Local RCFE Licensures ..................................................................38
Ownership and Organization ...........................................................................39
Legal Entity Validation ....................................................................................41
License .............................................................................................................42
Dementia Care: No Findings ...........................................................................46
Additional Special Approvals: No Findings ....................................................47
License Correctness .........................................................................................47
Staff ........................................................................................................................48
Skilled Medical Professionals ..........................................................................49
Ancillary Staff: Kitchen, Culinary, and Housekeeping ...................................49
Caregivers ........................................................................................................50
Staff: Total by Strata ........................................................................................50
x
English Speaking Caregivers ...........................................................................51
File Completeness ............................................................................................52
Finances .................................................................................................................53
Monthly Revenues and Per Day Rates.............................................................53
Food Costs and Per Resident Food Costs Per Day ..........................................55
Profits ...............................................................................................................56
Enforcement ...........................................................................................................56
Citations by Type .............................................................................................58
Citations by Regulation and Strata ..................................................................59
Top Ten Regulations by Strata ........................................................................62
Civil Penalties ..................................................................................................62
Errors in Assessing Civil Penalty Amounts .....................................................64
Licensing Program Analyst Citation Patterns ..................................................66
5
DISCUSSION ..............................................................................................................69
Facility Characteristics...........................................................................................69
Finances .................................................................................................................70
Enforcement ...........................................................................................................71
File Condition ........................................................................................................72
Implications of the Data .........................................................................................72
Recommendations for Future Study ......................................................................80
License Reliability ...........................................................................................80
Financial Data ..................................................................................................81
Civil Penalties ..................................................................................................81
xi
6
LIMITATIONS ............................................................................................................83
Missing Documentation .........................................................................................83
Limited Data: One Region .....................................................................................83
Limited Data: Facilities not Residents ...................................................................84
Qualitative Data .....................................................................................................84
Financial Data ........................................................................................................84
Data Collection Techniques ...................................................................................84
7 CONCLUSIONS..........................................................................................................85
Non-Medical Model is a Fiction ............................................................................85
Regulatory Gaps are Myriad ..................................................................................86
Missing Data from the Public Record ....................................................................86
REFERENCES ........................................................................................................................88
APPENDICES
A SAMPLE LIC 809 .......................................................................................................94
B CPRA REQUEST LETTER ........................................................................................96
C RCFE FILE ORGANIZATION...................................................................................99
D VARIABLES COLLECTED, WITH SOURCE........................................................101
E SAMPLE LIC 401 .....................................................................................................106
F CODE DICTIONARY (FOR INSPECTIONS SHEET IN WORKBOOK)..............108
G SAMPLE LIC 9099 ...................................................................................................113
H CROSSWALK FROM PRE-2008 REGULATIONS TO POST-2008
REGULATIONS........................................................................................................115
xii
LIST OF TABLES
PAGE
Table 1.Progressive Compliance and Enforcement Actions....................................................11
Table 2. Stair-Stepped Requirements Based on Facility Size..................................................14
Table 3. Stratification by Bed Size ..........................................................................................29
Table 4. Baseline File Count to Requested Sample .................................................................29
Table 5. Actual Sample File Count by Size Stratification .......................................................29
Table 6. Facilities by Organizational Type Compared to Flores, Bostrom, et al., 2008 .........40
Table 7. RCFEs Disqualified by CASOS by Disqualification Type .......................................41
Table 8. Examples of License (LIC 203A) Content Inconsistencies .......................................43
Table 9. Supporting Documentation for CCL Approved Waivers ..........................................45
Table 10. Coding of License Correctness ................................................................................47
Table 11. License Content Matched Supporting Documents in File .......................................48
Table 12. Caregivers (by Category)/Per Facility/By Strata .....................................................50
Table 13. Total Categorized Staff by Strata.............................................................................51
Table 14. Requirement for English Language Competence ....................................................52
Table 15. File Completeness of LIC 500 Personnel Report ....................................................53
Table 16. Missing LIC 500s by Strata .....................................................................................53
Table 17. Summary of Financial Findings, by Strata, by Variable..........................................54
Table 18. The USDA Low-Cost Per-Day Food Plan Compared to the Range of Costs for
RCFE, within each Strata .............................................................................................55
Table 19. Summary of Discrete LPA Actions .........................................................................57
xiii
Table 20. Citation Types by Strata ..........................................................................................59
Table 21. Type A Citations per Strata Beds ............................................................................59
Table 22. Top Ten Citations, by Regulation ............................................................................60
Table 23. Civil Penalties Assessed vs. Paid .............................................................................63
Table 24. Noncompliance Conferences as Percentage of Strata..............................................65
Table 25. Number of Citations, by Type, by Licensing Program Analyst ..............................66
Table 26. CCLD File Organization ........................................................................................100
Table 27. File Protocol Sheet (FPS) Fields ............................................................................102
Table 28. Facility List Fields .................................................................................................103
Table 29. Staff Sheet Fields ...................................................................................................104
Table 30. Evaluation and Complaint Sheet Fields .................................................................105
Table 31. Code Dictionary (Used to Code Sheet 4, Inspections) ..........................................109
Table 32. Cross Walk between Pre- and Post-2008 Title 22 Regulation Numbers ...............116
xiv
LIST OF FIGURES
PAGE
Figure 1. New licensures by year .............................................................................................39
Figure 2. RCFE grwoth by strata, 2000-2008 ..........................................................................40
Figure 3. Flow chart for Amb/Non-Amb, hospice, bedridden validation coding ....................44
Figure 4. Specialized staff employed by RCFEs .....................................................................49
Figure 5. The top ten citations by strata ...................................................................................61
Figure 6. Facility noncompliance conference characteristics ..................................................66
Figure 7. LIC 809 .....................................................................................................................95
Figure 8. CPRA request letter ..................................................................................................97
Figure 9. Enclosure 1 to C.M. Murphy ....................................................................................98
Figure 10. LIC 401 .................................................................................................................107
Figure 11. LIC 9099 ...............................................................................................................114
xv
GLOSSARY
ALF
Assisted Living Facility
CCL
Community Care Licensing, Department of Social Services (California)
CCLD
Community Care Licensing Division, an agency of California’s DSS
CMS
Centers for Medicare and Medicaid
CNA
Certified Nurses Assistant
CPRA
California Public Records Act
DOJ
U. S. Dept of Justice
DSS
Department of Social Services (California)
HCFA
Health Care Financing Administration (Federal Agency)
LPA
Licensing Program Analyst
LUM
Licensing Unit Manager, Supervisor of the LPA
LVN/LPN
Licensed Vocational Nurse/ Licensed Practical Nurse
N/A
Non-Ambulatory
PoO
Plan of Operation
QOC
Quality of Care
QOL
Quality of Life
RCFE
Residential Care Facility for the Elderly (California)
RN
Registered Nurse
SNF
Skilled Nursing Facility
xvi
ACKNOWLEDGEMENTS
Who knew that placement of my mother in an RCFE in 2003 would set in motion a
series of events leading to this paper, and to the establishment of a not-for-profit organization
dedicated to making public information about RCFEs available on the web to consumers of
long-term care?
With great thanks, I acknowledge the assistance of the following
individuals who facilitated, encouraged, or supported this endeavor:
To the individuals at Community Care Licensing Division of the State of California’s
Department of Social Services, I thank and appreciate the significant efforts of those who
made the review of 348 files possible, and who daily assisted me in so many ways: Lisa
Quinlivan, Bethany Hunter, Cynthia Diaz, Cheryl Funston, Myron Taylor, and to the
anonymous LPAs who willingly answered questions and provided file clarification;
To Chrisy Selder, who provided the impetus that moved this thesis out of the
floundering stage and on to paper, for her support, enthusiasm, and willingness to be a
sounding board, for her time spent reading, and making brutal and extensive edits to early
manuscripts – it is a considerably better document for her efforts. And of course, especially
for her friendship;
To Dr. Garrett who fielded my questions with patience, who provided assistance to
augment my weak SPSS skills, for the academic support and encouragement to get me to the
finish line, for giving up parts of his weekends and evenings to read and comment on this
document, and for always being on-call for me;
To Dr. C. Depp, (Stein Institute for Research on Aging, UCSD), and Dr. T.
Finlayson, (Graduate School of Public Health, SDSU), for their agreement to sit on my
xvii
Thesis committee, and for their generous commitment of time and effort to read, comment
and offer valuable insights to the content of this paper;
To A. S. who guided me to the understanding that Spirit works through service;
And of course to my family: Carl, Carmen, Toaster, Sherpa, Terfel and
TangoMurphy who bravely survived not having much of a wife or mom in the house for
several years, and especially not during the months this document was written. Carl, your
support, encouragement, math help, and cooking dinner made the difference between taking
on this project, and seeing it accomplished, and not doing so.
Any errors in this manuscript are mine.
I am fairly certain that given a Cape and a Tiara, I could save the world - Really.
1
Chapter 1
INTRODUCTION
The United States is getting grayer, the fastest growing demographic in the U. S. is
the over-85 population, and by 2050 the number of Californians over 65, are expected to
reach 11 million (California Health and Human Services Agency [CHHS], 2003). The aging
boomer-bubble has been likened to a massive ocean liner approaching an empty shoreline at
cruise speed, and we have yet to build a dock to accommodate the ship’s arrival.
As the Boomer population of 76,000,000 continues to age, the requirement for a
variety of long-term care options takes on a tone of urgency. Sooner or later, each of us
will become a consumer of long-term care – either for ourselves or as surrogate for a family
member: industry analysts project that approximately 70% of individuals who turned 65 in
2008, will need some type of long-term care in their lives (Redding, 2008).
This paper focuses on operational irregularities found in the licensure, regulation
and enforcement of California Code of Regulations (CCR), Title 22, for the type of longterm care known in California as the Residential Care Facility for the Elderly, or the RCFE
(CCR, 2010). The term “irregularity” as used in this paper refers to a failure, defect, gap, or
departure from a regulation or law, or commonly-held practice, as seen through analysis of
data collected from the public files of RCFEs.
This paper presents descriptive data of irregularities evident in the assisted living
sector of long-term care: irregularities compromising the reliability of regulators to regulate
the industry, and those calling into question how care is delivered. This paper will contribute
to the slowly-accumulating body of literature about the least-regulated, and fastest growing
segment of the long-term care continuum – RCFE (California Political Desk, 2008; Carlson,
2005; Hawes, Phillips, & Rose, 2000).
2
Public File as Proxy
The window available to understanding the operation, staffing, finances and
regulation of the RCFE is through the public file. It is compiled on each licensed RCFE by
its regulator – Community Care Licensing Division (CCLD); the file is, by default, the proxy
for the RCFE. The public file reveals both patterns in the state’s regulation and enforcement
of Title 22 regulations; and patterns of operation within the RCFE itself. Admittedly, this
methodology for accessing complete information about RCFEs is flawed, but until California
initiates stringent reporting requirements on RCFEs as Centers for Medicare and Medicaid
Services (CMS) imposes on Skilled Nursing Facilities (SNF), the public file remains the best,
thought not the perfect, source of available information.
Study Design
This is a ten-year (2000 – 2009) retrospective descriptive study of the public files
of 348 RCFEs located in San Diego and Imperial Counties. Because RCFEs are privately
owned care homes, take no government money for resident services, and are not regulated
by federal standards, they are an understudied and under described long-term care option
(Curtis, Kiyak, & Hedrick, 2000). The public file therefore, was recognized as a rich source
of information for mining descriptive data which may offer insights about both the RCFE and
the agency who licenses and regulated them – the Community Care Licensing Division of
California’s Department of Social Services.
This study’s basic design was derived from two 2008 companion reports: “Inspection
Visits in Residential Care Facilities for the Elderly,” by C. Flores, A. Bostrom, R. Newcomer
(2008), and “Quality of Care in Residential Care for the Elderly,” by C. Flores, R.
Newcomer, J. Fecondo, and T. Donnelly (2008), both funded by the California Health Care
Foundation.
3
Literature Sources
Beyond a few notable exceptions (the works of R. Newcomer and C. Harrington),
there is limited literature investigating, describing, or evaluating RCFEs in California.
Also limited is scholarly literature addressing Assisted Living (AL) nationwide, although
R. Mollica and C. Hawes have been at the forefront of this research (Hawes et al., 2000;
Hawes, Phillips, Rose, Holan, & Sherman, 2003; Mollica, 2006; Mollica, Sims-Kastelein,
& O’Keeffe, 2007). These sources, however useful, are limited in scope, and do not address
some findings of this study. This study had to cast a wider net to the more-researched nursing
home literature, to regulation of California’s childcare facilities, and to data archival and
reliability experts to contextualize the RCFE literature and findings of this paper.
Nursing Home Data
Nursing homes, also called Skilled Nursing Facilities (SNF), are institutional live-in
settings providing 24/7 medical care to sick and frail elders. Because SNF services are paid
for through Medicare and/or Medicaid, comprehensive reporting requirements are requisite
to acceptance of government money for services rendered. These “strings” are the method
by which the government has been able to learn about SNF resident demographics, staffing,
quality of care outcomes and the finances of the business of providing care. The extensive
SNF data set collected by Centers for Medicare and Medicaid Services (CMS) has been
fertile ground for academic study. Studies suggest SNFs and AL facilities shelter similarly
frail residents who need assistance with many ADL dependencies; as a result, much of the
nursing home literature has direct relevancy to the RCFE.
Child Care Facilities
California State Auditor reports addressing issues within the Child Care component
of Department of Social Services, Community Care Licensing Division (CCLD) were helpful
because there are parallels with CCL’s oversight of RCFEs as well. CCLD is responsible for
licensure, oversight, and enforcement not only of residential elder care facilities, but child
4
care congregate living facilities as well. Most aspects of licensure, periodic visits, record
keeping, access to public documents, enforcement, and facility closures in Child Care are
identical to those employed in Residential Elderly Care. Because of this association, relevant
academic works from childcare group living will contribute to this literature review.
Terminology
Regulation of assisted living facilities falls to the states, as there is no federal
oversight of the industry (Newcomer & Maynard, 2002). In California, licensure and
oversight for community-based non-medical facilities resides with California’s Department
of Social Services (DSS). DSS, through its Regional Community Care Licensing Division
(CCL) offices, is responsible for the oversight of four programs: Child Care, Child
Residential, Adult Care, and, through its Senior Care Program: the Residential Care Facilities
for the Elderly (RCFE) Program (Barnes & Sutherland, 2001). As of January 17, 2009,
exactly 8,200 licensed RCFEs provided statewide capacity of 174,738 beds (Community
Care Licensing Division, 2009).
The Senior Care Program provides cognizance over both RCFEs, and another longterm care housing option – the Continuing Care Retirement Community (CCRC). The
CCRC is unique in that a resident turns over substantial assets to the CCRC, in exchange
for the CCRC’s pledge to provide life-long, long-term care services to the resident. Many
aspects of licensure are different from how RCFEs are licensed, and financial oversight is
much different, given the long-term escrows required by these organizations (California
Department of Social Services, 2010). All unique parameters of the CCRC are considered
beyond the scope of this paper, and are therefore, not discussed.
The department provides comprehensive oversight of RCFEs beginning with facility
licensure. Once the facility is licensed, CCL’s mandate is to periodically evaluate the
facility, to conduct investigations for complaints and incidents as they are reported, and to
conduct necessary case management visits. When a facility ceases to operate (resulting from
5
administrative agency decisions, or voluntary Licensee actions), CCL confirms closure to
assure residents have been appropriately re-placed.
An RCFE is distinguished from a nursing home or skilled nursing facility (SNF) in
that it is a non-medical housing arrangement, based on a social model rather than a medical
model, and is licensed by the Department of Social Services rather than the California
Department of Public Health. A significant distinction is that RCFEs are exclusively private
pay, whereas most SNF-provided services are reimbursed through Medicare and/or Medicaid.
Title 22
RCFEs are licensed and regulated pursuant to the California Code of Regulations,
Title 22, Division 6, Chapter 8 (2010), which includes portions of the Health and Safety
Code. In addition to state law, RCFEs are subject to applicable Fire Marshal code, and
municipal (zoning, planning, building, et al) codes. Title 22 will be referred to by its name
(or “the regulations”), as an umbrella term to refer to the Title 22, Division 6, Chapter 8
regulations specifically applicable to RCFEs. Specific regulations will be cited by their
5-digit number (i.e., §87560).
Title 22 defines a “Residential Care Facility for the Elderly (RCFE)” as a,
...housing arrangement chosen voluntarily by the resident...or other responsible
person; where 75% of the residents are 60 years of age or older and where varying
levels of care and supervision are provided, as agreed to at time of admission or as
determined necessary at subsequent times of reappraisal (CCR, §87560, 2010).
This definition is unique to California; there is no nationally recognized definition of assisted
living (Hawes, Rose, & Phillips, 1999; Hawes et al., 2000).
The regulations represent a “one-level licensure system” (Carlson, 2005) as they
apply to all RCFEs licensed in California, regardless of capacity (measured in beds).
However, not all individual requirements apply to all facilities; some requirements are stairstepped. For example, all facilities must offer activities for residents, yet in CCR Title 22
§87579 (2010), 7-16 bed facilities must post a schedule of activities, in 16-49 bed facilities
one staff member (with 6 months activities experience) must be designated as the activities
6
director, and in facilities with 50+ beds, one full-time staff member shall be responsible for
activities and that person must be provided with additional staff as required to assure all
residents participate in activities consistent with their interests, abilities, and choices.
LPAs
Individuals who perform inspections, investigate complaints, and perform such
other duties as required by CCL are known as Licensing Program Analysts (LPAs); in
law enforcement parlance – they are the “beat cop.” They are the front-line employees
for RCFE licensure and regulation (Short & Toffel, 2008). LPAs must sign all LIC 809s
(Facility Evaluation Reports) and LIC 9099s (Complaint Investigation Reports) prepared
by them. LIC 809s and LIC 9099s are prepared at the time the evaluations or inspections
are performed. Responding to recent budget cutbacks and resource limitations, facility
evaluations (LIC 809s), once required annually, are now only required once in five years;
complaint and unusual incident reports (UIRs) are generated when complaints or UIRs are
investigated.
Resident Characteristics
The typical resident of assisted living is a white, widowed, well-educated, somewhat
affluent female, between 75 and 85 (Hawes et al., 2000; General Accounting Office [GAO],
2004), needing assistance with activities of daily living (ADLs) due to physical frailty or
cognitive impairment (Hawes et al., 2000). Title 22 requires facilities to retain information
(medical assessments, change of condition, emergency contact) about each resident, but
the data resides only in the facility, and is subject to review only by CCL personnel. If the
state obtains resident-specific information, it is retained in a confidential file, not subject to
public disclosure or review. The state does not collect resident demographics or functional
characteristics (Newcomer & Maynard, 2002), as does Centers for Medicare and Medicaid
(CMS) through its Minimum Data Set (MDS) for SNF residents (Anderson, Hobbs, Weeks,
& Webb, 2005).
7
Licensing
The licensing process is initiated by the individual or organization opening a facility.
The DSS website (www.dss.ca.gov) details the documents and submittals required to obtain
licensure. Many of these application documents become part of the public file including
the LIC 203A - Application, evidence of control of property to be used as the RCFE,
organizational and administrative data, Plans of Operation describing the philosophy of care,
and services to be offered.
Before licensure, the Licensee must show evidence of three months of ready assets
necessary to cover the first three months in business. The amount is established through
the applicant’s submittal of a monthly estimate of revenues and expenses (LIC 401). The
state multiples the monthly estimate by three to determine the 3-month asset requirement.
Assets can include bank balances for checking and savings accounts, as well as lines of
credit on major credit cards. The Licensee’s application package must also include written
authorization to the Licensee’s financial institutions allowing the financial institution to verify
to CCL the credit limits and cash asset balances reported by the Licensee.
Facility Administrators
A mandatory condition of licensure is that the facility have a Certified Administrator.
The Administrator is the individual responsible for operating the facility, and supervising
the resident care in compliance with Title 22 requirements. This person can either be the
Licensee, or a hired employee. Either way, the Administrator must be certified through 40
hours of training provided by a state-qualified vendor, and must have received a passing
score of 70+ on the state examination. To remain a Certified RCFE Facility Administrator, an
additional 40 hours of continuing education is required every two years, along with payment
of a renewal fee. The prerequisites for becoming an administrator are dependent upon the
size of facility being administered.
8
Pre-Licensing
Other conditions precedent to licensure include a series of pre-licensing meetings
with CCL staff, and a facility evaluation to assure all physical requirements of Title 22 have
been met.
Visit Types
Once licensed, CCL performs unannounced mandated (annual, random annual, fiveyear) and ancillary evaluations (case management, collaterals) of the facility. Additional
unannounced visits follow CCL’s receipt of a complaint against the facility, or upon
notification of an unusual incident occurrence at the facility. Complaints can be made by
any person, (resident, family member, 3rd party provider such as hospice or adult day-care),
by calling CCLs daily duty officer, or by filing a formal written complaint. Facilities are
required by Title 22 to file Unusual Incident Reports (UIRs) for various occurrences (falls,
fires, resident violence, etc.) in the facility. It is also common for city or county agencies
(Police, Fire Departments, LTC Ombudsman) to report complaints or incidents related to
9-1-1 calls.
Non-Medical Model Providing Medical Services
Assisted living facilities have long been portrayed as comely residential settings
where an individual lives in a home-like setting, receives limited assistance with daily
activities, while maintaining an independent, active, and busy life. This image is becoming
anachronistic with the recognition that RCFEs are “serving an increasingly impaired
clientele” (Curtis et al., 2000). Many assisted living residents have chronic medical needs in
addition to deficits in activities of daily living. The anomaly of an RCFE is that, by definition
it is a non-medical housing alternative, yet they may retain residents on hospice, individuals
who require oxygen administration, intermittent positive pressure breathing machines or
indwelling urinary catheters, bedridden clients, diabetics, and those with Stage 1 and 2
decubitus ulcers. Each is a serious, and frequently, chronic medical condition allowed by
9
the regulations, notwithstanding that Title 22 contains no requirement for on-staff skilled
medical professionals. Short of complaint information in the public file when a negative care
outcome from one of these medical conditions occurs, there is little opportunity to assess
health and care outcomes resulting from allowing these medical conditions to be managed
by unskilled care staff for the following reasons: (a) because the RCFE is a non-medical
model, CCLD does not track, or require reporting of residents’ health outcomes, and (b)
any complaint or unusual incident information concerning adverse resident-related outcome
information will be placed in the Confidential file of the RCFE where the complaint or
incident originated – thereby shielded from public scrutiny.
While Title 22 specifically defines RCFEs as non-medical housing arrangements,
there is growing contingent of professional and academic observers who take issue with
this characterization. Lenhoff notes that assisted living facilities look more like nursing
homes than assisted living facilities given the ever-increasing migration of frail elders into
these facilities. She observes that increased medication errors are but one manifestation of
the collision between regulations supporting a non-medical model, and an on-the-ground
reality of the many chronically infirm residents living in these minimally-regulated facilities
(Lenhoff, 2005).
Also contributing to the growing perception of assisted living facilities as being mininursing homes, have been policy decisions in some states to “…substitute[d] residential care
beds for nursing home beds in their long-term care system,” in part because assisted living is
seen as less costly than SNFS for the taxpayer (Hawes et al., 2000). Additional changes to
many states’ policies eliminated health condition prohibitions which restricted owners from
accepting hospice residents, and residents with increasingly severe cognitive impairment
(Hawes et al., 2000). One thing is beyond dispute – the residential care facility in its 21st
century form, is blurring the line between skilled nursing care, and assisted living.
10
Enforcement
Title 22 provides CCL with progressively onerous options to encourage Licensee’s
regulatory compliance. The most benign of these is the citation; citations are issued
according to the seriousness of the violation. A Type A cite is issued for Serious Deficiencies:
those posing an “... immediate or substantial threat to the physical health, mental health or
safety of the residents” (CCR, Title 22, §87451, 2010). Type A citations must be corrected
within 24 hours. All other citations are Type B, which must be corrected within 30 days
from date of citation. Other enforcement tools used to encourage compliance with laws and
regulations, include (in order of severity): Civil Penalties, Non-Compliance Conferences,
Formal Accusations, Temporary Suspension Orders, Administrative Hearings, and Facility
Closures (Community Care Licensing Division [CCLD], 2007).
The Continuum of Compliance and Enforcement
Community Care’s Evaluator’s Manual (CCLD, 2007) advises that LPAs have
three “program components” at their disposal to assure achievement of their mission to
protect the health and safety of elders residing in RCFEs: Prevention, Compliance and
Enforcement. Compliance is achieved through inspections, deficiency notices, and providing
“consultation…[for] correction of deficiencies,” while enforcement is the disciplinary action
taken by CCLD when a provider fails, is unwilling, or unable to maintain compliance with
Title 22 regulations (CCLD, 2007). Based on the Evaluator’s Manual (CCLD, 2007), the
hierarchy of tools that can be used by the CCLD is shown in Table 1.
Consumer Advocates for RCFE (Residential
Care Facilities For The Elderly)
Reform (CARR)
Consumer Advocates for RCFE Reform (CARR) is a start-up Not-for-Profit
organization, with multiple missions. Focusing on the licensed RCFEs in San Diego and
Imperial counties,
• CARR will obtain via detailed CCLD public file review copies of all LIC 809s and
9099s in the public record, create scans of the complete document, and post the
11
Table 1. Progressive Compliance and Enforcement Actions
action
Citation – type a
Citation – type B
Civil penalties
Non-Compliance
Conference
administrative
actions and other
Legal Options
applicable to…
Deficiencies requiring immediate
correction as they jeopardize the
health and safety of residents
Deficiencies which do not
immediately jeopardize the health or
safety of residents but which must be
corrected to restore the facility to
compliance with Title 22
1. Failure to meet the Plan of
Correction due date for a citation.
2. Repeat Violations
3. Failure to comply with Criminal
Background and Association
requirements
4. Violations leading to Death,
Injury, or Sickness of Client
Features
Requires correction within 24
hours of date of citation. (Plan
of Correction)
Requires Licensee correct the
deficiency within 30 days
from the date of the citation.
(Plan of Correction)
LPA does an analysis of the types
and number of serious deficiencies
using the Case Assessment Protocol
(CAP). If the Licensee meets the
requirements outlined in the CAP he
is notified of a mandatory meeting to
be held at the Regional office.
When a Licensee continues a pattern
of serious deficiencies, fails to
perform to the Non Compliance Plan,
or commits other egregious acts that
endanger residents, CCL can initiate
Administrative Actions for resident
relocation and facility closure. CCL
may have other legal recourse as
well.
CCL personnel, and Licensee
personnel meet to discuss
failures to comply with Title
22, with the outcome being a
Facility Compliance Plan.
Sometimes results in quarterly
inspections for one year.
Outcomes of Administrative
actions include:
• Temporary Suspension
Orders
• Implementing a Decision
& Order Revoking
License or such other
terms of the Order
Civil Penalties are progressive
(1st cite, 2nd within 12 month
period, 3rd or subsequent) and
vary by type of infraction,
amount, and duration. $50 to
$150/day to $1,000 immediate
CP, and $100/day until
corrected for 3rd citation.
documents on CARR’s website. Further, CARR will obtain other documents as are
in the public record related to any licensed RCFE (law suits, criminal and police
records, Administrative Law Actions, and Fire Marshal records) and post those public
documents on the website.
• The on-line documents will be presented in a searchable database, allowing
consumers to access otherwise nearly-inaccessible public files residing in CCL
offices. Currently hardcopy files are available only by visiting the CCLD office,
after first having made a public records request. For the general public the time lag is
about 5 days from request, to file review date. If a consumer living in San Francisco
wants to research an RCFE in San Diego county, that consumer must visit the San
12
Diego office to review the file. The CARR website will eliminate that inconvenience
for the consumer.
• File surveillance will be done once a year, with documents updated appropriately.
• CARR will provide additional consumer-related information about RCFEs in
California, provide regular updates on pending legislation, and will maintain a blog –
publishing white papers advocating reform of the regulations.
• CARR will also engage in educating consumers of long-term care, as well as
legislators about the inequities and gaps in Title 22 regulation and enforcement
practices, with the objective of creating a critical mass for change.
Unless otherwise noted, all data in tables and figures has been furnished and are
copyrighted by CARR.
13
Chapter 2
LITERATURE REVIEW
The assisted living industry has grown rapidly over the last twenty years - the
confluence of several factors: the large boomer population needing assisted living for either
themselves or their parents; cheap money and HUD-subsidized mortgages made housing,
facility renovations, and construction affordable; and assisted living is seen as a lessrestrictive alternative to nursing homes.
The long-term care industry anticipates continued growth based on projections of
future need: The Lewin Group reports that about 13% of the over 65+ population will
spend part of their lives in assisted living, and projects that by 2050 “elderly long term care
users” will double over the 2010 number (The Lewin Group, 2010). Individuals needing
daily assistance prefer living in more home-like environments, over institutional, nursing
home settings (Hawes et al., 2000). The housing bubble also contributed to the burgeoning
industry: availability of easy money and mortgages (some subsidized by programs under the
National Housing Act [Section 232] (GAO, 2006), likely contributed to the near 67% growth
in RCFEs between 1990 and 2002 (Harrington & O’Meara, 2007). Assisted living has
become an increasingly “popular long-term care option” (GAO, 2004), given impetus by the
1999 U. S. Supreme Court’s Olmstead Decision which held that persons were entitled to live
in the least restrictive setting which could reasonably accommodate their needs
(Olmsted v. L.C., 1999).
Facility Size and License
Facilities vary in size, from as small as one or two beds, to over 500 beds in the
corporate model. Title 22 accommodates licensure of facilities of any size – the one-level
licensures described by Carlson (2005), however “licensing standards and regulations” are
14
size dependent (Newcomer & Maynard, 2002). How Title 22 adapts a regulation to everincreasing populations (stair-stepping) is illustrated in Table 2 (CCR, Title 22, §87564 &
§87576, 2010).
Table 2. Stair-Stepped Requirements Based on Facility Size
Administrator
Qualifications
(§87564)
Food
Preparation
(§87576)
Strata 1
1 –6 beds
Strata 2
7 –16 beds
Strata 3
16 –49 beds
Strata 4
50 – 99 beds
High school
diploma or
GED
Certificate
High school
diploma or
GED
Certificate
2 years
college
2 years
college
No
Residential
care
Experience
No
Residential
care
Experience
15 college
units, CE
Sem or equiv
quarters w/
passing grade
3 years in
residential
care
3 years in
residential
care
No
requirements
No
1 person
requirements designated
w/ primary
Caregiver
resp. for food
staff prepare planning,
meals
prep &
service
w/training
1 full-time
person
qualified by
formal
training or
experience
resp for food
service.
Requires
regular
consult with
dietician.
1 full-time
person
qualified by
formal
training or
experience
resp for food
service.
Requires
regular
consult with
dietician.
Caregiver
staff prepare
meals
1 Yr
Residential
Experience
Strata 5
100+beds
Size and Ownership
Size also tends to characterize ownership: Individual ownership or sole
proprietorships tend to be the smaller 1 to 6 bed facilities; this strata represents fewer overall
beds but more facilities, while corporate facilities tend to be large (100+ beds), account
for the majority of capacity, but represent many fewer facilities (Harrington, Chapman,
Miller, Miller, & Newcomer, 2005; Harrington & O’Meara, 2007). Organizational models
for assisted living ownership also vary - from individual ownership (sole proprietorships)
15
to fictitious persons (partnerships, limited partnerships, not-for-profits and corporations)
although the predominant model is the for-profit facility. A survey of assisted living
facilities in the state of Washington (Curtis et al., 2000) found that the majority (78%) were
for-profit entities, while in Harrington’s nursing home sample, 65% were for-profit facilities
(Harrington, Woolhandler, Mullan, Carrillo, & Himmelstein, 2001).
Licensing
Once licensure requirements have been met, the facility is licensed by the state to
open for business and begin accepting residents. The License (LIC 203A) is the authorizing
document allowing the facility to operate a residential care facility for the elderly (§87101(l))
at the Basic Service level (§87101(b)) (CCR, Title 22, §87101, 2010). Basic Services are
defined in §87101(b) as “those services required to be provided by the facility in order to
obtain and maintain a license...including safe and healthful living accommodations, personal
care and assistance, and food services” (CCR, Title 22, §87101, 2010). The license issued by
the state must be posted in plain sight, in each facility.
Beyond provision of Basic Services, Mollica et al. (2007) report that assisted living
allows a resident to age-in-place (just as she would in her own home), as many states
authorize “incidental medical services” to be rendered. With approval from the state,
additional care services can be offered to residents who would otherwise have to move to a
higher level of care (Newcomer & Maynard, 2002; Street, Burge, & Quadagno, 2009). The
facility’s ability to augment its services in this way allows retention of a resident who would
otherwise have to move to a higher level of care because their care needs would exceed
the licensing limitations of the facility. For the resident and her family, this is a preferred
solution as it allows the resident to continue to live in a comfortable environment that she
knows, while sparing her the deleterious effects of “transfer trauma.” Transfer trauma
describes the resident’s adverse consequences of being uprooted from one location and
moved to another. Depending on the resident’s diagnosis, Transfer Trauma may propel the
patient into severe depression or result in extreme confusion (Corrigan, 2003).
16
Staff
Staffing is the cornerstone component of assisted living resident care: adequate
staffing results in better quality resident care (Harrington et al., 2001; Schnelle et al., 2004),
and helps assure residents’ dietary and nutritional needs are met (Burger, Kayser-Jones, &
Bell, 2000). Also, higher staff-to-resident levels tend to be associated with fewer deficiencies
and citations (Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000), while lower
staffing is associated with investor-owned and for-profit nursing homes, as compared to NFP
staffing levels (Harrington et al., 2001).
Adequate Staffing versus Staff-to-Resident Ratios
Deficits among residents in residential care/assisted living facilities have similarities
to residents living in SNFs (Kopetz et al., 2000). California’s mandated SNF nursing staffto-resident ratio is 3.2 hours-per-resident-day (hprd); the nationally recommended hprd is
nearly an hour higher at 4.1(Harrington, 2004; Harrington & O’Meara, 2007). Yet despite
mandates and recommendations, the Department of Health and Human Services reported
that 97% of SNFs were “severely understaffed” (Harrington et al., 2000; Lenhoff, 2005).
Similarly, surveys of SNF residents and families of residents indicate insufficient staff to
adequately assist cognitively impaired residents with eating (Burger et al., 2000).
Despite acuity levels being similar among residents of both SNFs and residential care
facilities (Hawes et al., 2003), only 19 states have some type of mandated assisted living
staff-to-resident ratio (Polzer, 2010).
Most other states require staff to be “sufficient” or “adequate” to accommodate
resident needs. California’s regulations are a hybrid, requiring “staff in sufficient numbers”
to adequately meet resident needs (CCR, Title 22, §87565, 2010), yet specifically stating an
awake night staff-to-resident ratio (1:15) for facilities retaining dementia residents (CCR,
Title 22, §87705, 2010).
With the exception of a requirement for one awake night staff in facilities of
16-to-100 residents, Title 22 does not have a minimum staff-to-resident ratio (Carlson, 2005).
17
It does however have bathroom-to-resident ratios (CCR, Title 22, §87577(b)(1), 2010), “one
toilet and washbasin for each six (6) persons,” and shower-to-resident ratios (CCR, Title 22,
§87577(b)(2), 2010) “one bathtub or shower for each ten (10) persons.” Rather, Title 22
requires a facility to staff “in sufficient numbers” to accommodate resident’s needs (CCR,
Title 22, §87565, 2010). Evidence that a facility has insufficient staff generally surfaces via a
substantiated complaint involving resident injury or death.
Ancillary Staffing
If regulatory staffing ratios did exist for residential care facilities, they would be
difficult to achieve without additional regulatory changes requiring dedicated culinary,
housekeeping, and maintenance staff: in smaller Strata 1 facilities, a single staff member
wears many hats, frequently having responsibilities for housekeeping, laundry and food
preparation, in addition to caring for residents (Carlson, 2005; Hawes et al., 2000).
Caregivers and Language
Newly hired facility staff members are reported to have less experience, and poor
English language skills (Newcomer & Maynard, 2002). The California Health Interview
Survey 2001 reported that 89% of its respondents responded to the interview in English
(Ponce et al., 2004). Further, U.S. Census data for 2000, reports that 60.5% of Californians
spoke only English, with another 19% who spoke a language other than English but
reported speaking English very well. Those combined percentages suggest that about 80%
of California’s population speak English (U.S. Census, 2002). From that data, one can
extrapolate that at least a majority of the assisted living population speaks English.
An Assisted Living Federation of America (ALFA) article addressed the issue of
English-speaking as a job skill for caregivers (Nickerson, n.d.). This article reports that
“more than 70% of the work force [in assisted living organizations] may speak English as a
second language. “ The article continues, “In California...state regulations require that all
employees are able to communicate effectively with the residents. This means assisted living
18
communities must carefully screen candidates so...they can meet the regulations, making it
very clear during the interview process that English-speaking skill is required”
(Nickerson, n.d.).
Self-Reported Staffing Levels
Because adequate staffing is an essential component of a resident’s quality of care
(Burger et al., 2000; Harrington et al., 2000; Schaffner, 2008; Schnelle et al., 2004), the
LIC 500 Personnel Report in each RCFE file was reviewed. There was no method to
independently verify the self-reported staffing levels shown on the LIC 500 Personnel Report
either through time cards or payroll records, therefore the findings regarding STAFF can only
be suggestive of actual on-the-ground RCFE staffing.
Finances
Little is known about the business of running an RCFE (Hawes et al., 1999). They
are privately owned and operated; monthly room rental rates are largely market-driven, and
rate sheets are not posted; they accept no federal money for board and/or care services (save
small pilot programs in several California counties where Medicaid monies are paying for
some portion of RCFE services), and they are not required to file annual financial statements
with CCL. Against this blank financial page, the LIC 401 Monthly Financial Estimate
(Appendix A), a document submitted as part of the Licensee’s application package, offers
insight into the finances of the residential care facility.
This study looked at three components of the LIC 401: monthly revenues to derive
average monthly room rates, monthly food budget to derive the average per-resident/permonth allocation, and profits estimated by the Licensee.
Monthly Revenues and Per Day Rates
A licensed residential care facility must provide Basic Services (CCR, Title 22,
§87590, 2010): a room furnished with a bed, closet, dresser, lamp; three nutritious meals per
day, 2 snacks, and adequate hydration; and assistance with care needs as required. Across
19
facilities, there is variation in monthly rates: Curtis, Kiyak, and Hedrick (2000) reported
that 1997 daily rates in Washington state ranged from about $50/day to $69/day ($1,500
to $2,070/mo) depending on geographic location, and resident needs. Newcomer and
Maynard’s data (2002) reveals that single assisted living rates range from $40/day to $100/
day ($1,200 to $3,000/mo) with an average of $73/day ($2,200/mo). The GAO (2004)
reports a wider average range of assisted living base monthly fees are between $1,020 ($34/
day) and $4,429 ($147/day). There is no way to independently capture actual rates charged
without review of the actual (and confidential) admission agreements in each individual’s file
within any individual RCFE.
Despite RCFE’s being defined in state code as a “housing alternative,” this study
could find no evidence that residents qualify for state or federal senior housing subsidies, rent
control, HUD or affordable housing initiatives. RCFE owners however, can benefit from
HUD-subsidized mortgage insurance programs (GAO, 2006).
Monthly and Daily Food Allowance
Monthly raw food budgets are dependent on the type and quantity of food purchased
(fresh, prepared, tinned), and recognize that economies of scale are reflected in the bottom
line. A 1999 estimate of raw food cost per (assisted living) resident day, based on facility
capacity of 60, and reported by Newcomer and Maynard (2002) was $3.60 ($108/mo) for
a total per-resident cost of $1,315/year. Adjusting that figure at a modest 3% cost-of-living
increase for ten years, the present-day value would be approximately $1,709 annually, or
$142.42/mo ($4.74/day). The Center for Nutrition Policy and Promotion’s Official USDA
Food Plans for April 2009 for a 71+ year old male are higher: the Thrifty plan proposes
$155.10/mo ($5.17/day) and the Low-cost Plan is estimated at $203.40/mo ($6.78/day)
(USDA, 2009). The metric for computing per-day food costs is slightly different between
the two: Newcomer and Maynard’s (2002) figures are estimated for 3 meals a day, while the
USDA Food Plans are based on recommended food intake necessary to achieve a nutritious
diet (USDA, 2009).
20
Long shift hours, and inability of caregiving staff to leave the facility, staff generally
eat the same food as residents. Newcomer’s assisted living per-resident figures do not
account for staff meals; further the number of staff for whom meals are provided is highly
dependent on facility size, therefore the per-day-resident estimates are necessarily diluted by
some unknown number.
Providing for the nutritional needs of frail elders on low food budgets increases
the concern of malnutrition and dehydration among the facility population. Some study
results suggest that malnutrition among the nursing home and/or assisted living population
is as high as 60% (Ennis, Saffel-Shrier, & Verson, 2001; Evans, 2005). Allowing for other
possible causes of malnutrition including adverse drug affects, too few staff to assist with
feeding, culturally inappropriate selections, depression, badly fitting dentures, and too many
distractions at meal time to name a few (Ennis et al., 2001), the quantity and quality of food
must also be considered as contributors to poor nutrition.
Profits
Profitability of assisted living facilities is difficult to independently assess given the
absence of regulations requiring regularly recurring financial reporting. Trade industry
websites, restricted to members-only, address financial operation and profitability; Wall
Street also tracks performance of investor owned assisted living conglomerates. In 1997,
Beverly Enterprises, a large corporate health service organization owning both SNFs and
Assisted Living facilities, reported profits of $5.28 per-patient-day (Harrington et al., 2001).
Harrington and O’Meara’s (2004) research of nursing home profit margins suggests that
facilities with profit margins exceeding 9%, provide lower quality-of-care resulting from
reductions in staffing, and other services to improve facility profitability.
Enforcement
Studies among cited nursing homes showed that for facilities previously cited for
deficiencies, upon subsequent visits, the facilities again were found to be out of compliance
21
(GAO, 1999). Vigilant monitoring of performance therefore seems essential: SNFs have
two levels of surveillance (federal and state), and more frequent inspections to ensure
compliance with applicable licensing and Medicare compliance regulations. Medicare has
its own federal inspectors who audit facility performance, and contracts with individual state
agencies to perform additional surveys; CMS surveys are required approximately every 15
months on average (GAO, 2003; GAO, 2008).
The Joint Commission (formerly known as the Joint Commission on Accreditation
of Healthcare Organizations [JCAHO]), an independent, non-governmental, 3rd party, forfee accreditation organization, provides compliance audits to about 1,200 long-term care
facilities (predominately SNFs) but they have no citation or enforcement authority. At this
juncture, JCAHO is not a major force in surveillance or compliance for either assisted living
or SNF.
In SNF settings, federal inspectors have many more compliance and enforcement
options open to them, such as on-the-spot fine assessments, and preventing the facility
from further resident intakes until the facility moves into verifiable compliance (GAO,
2003; Harrington et al., 2001). If a facility is assessed a monetary civil penalty, collection
is not an issue: because SNFs receive their revenues from the federal government, nonpayment of civil penalties is easily remedied as the civil penalties are simply deducted from
reimbursements owing to the facility (GAO, 2007b). Because Assisted Living facilities take
no federal money for services rendered, payment offsets are not available as an enforcement
tool.
Despite the number of actions regulators (at both the federal and state levels) can take
against SNFs and AL facilities, a recent Kaiser Family Foundation poll revealed that over
60% of the public does not think there is enough government regulation of SNFs (Miller &
Mor, 2008). That perception may be real or apparent; perhaps adequate regulatory tools exist
but are just not applied as rigorously; trends have shown fewer citations have been issued,
over time, (Miller & Mor, 2008) causing one researcher to ask whether compliance
22
and/or quality has improved, or whether surveyors are being less aggressive in identification
of deficiencies (Miller & Mor, 2008). No similar studies exist for regulators of RCFEs.
In a study of nursing home enforcement patterns, findings suggested that inspectors
under cite or underestimate the severity of the deficiency (GAO, 2003; GAO, 2008). This
observation resulted from comparing the deficiencies cited first by state CMS inspectors in a
facility; those individuals were then followed by federal surveyors who identified and cited,
more and additional, serious deficiencies than had the state inspector who had just been there
(GAO, 2003; GAO, 2007a). Looking at citations patterns across states, CMS has recognized
variations in enforcement although it is unknown whether the variations are a product of
interpretation, lack of surveyor knowledge and education, time constraints of inspectors or
differing survey protocols (GAO, 2007a; Miller & Mor, 2008).
Others have suggested that the deficiency that gets cited is more a function of how
straight-forward the regulation is (i.e., water temperature must be between 105 and 120
degrees farenheit); harder to cite are those requiring judgment (Miller & Mor, 2008), the
more explicit the regulation the easier it is to enforce (Schaffner, 2008). If a citation requires
judgment, it is by its nature a subjective decision, not necessarily an objective statement of
the deficiency or circumstance (Schaffner, 2008). For these reasons, it becomes unclear
what the citation represents: an actual deficit in care quality, a subjective application of a
regulation, or the inexperience of the LPA (GAO, 2003).
LPAs Role as a Tool for Enforcement
As caregivers are to resident care, LPAs are to compliance and enforcement: both
are front-line functions. Caregiver knowledge and training are reflected in the quality of
care provided; so too, an LPA’s knowledge and training are reflected in the skill he brings to
the job of compliance and enforcement. And both depend on “sufficiency in numbers” to
accommodate the workload of their employers.
While the actual work load for an LPA depends on duty assignments at the regional
office level, the primary functions of the position include performing post-licensing visits;
23
timely performance of required visits (annuals, random annuals, and five year inspection) as
well as case management visits; follow-up on complaint and incident reports; evaluation and
processing of waiver and exception requests; processing and follow up on Licensee’s plans of
corrections; participation in non-compliance conferences, and related administrative actions
required by management (Barnes & Sutherland, 2001; CCLD, 2007). This researcher was
advised by CCLD individuals in the San Diego office, that the typical LPA workload is
between 120 and 150 RCFEs (C. Murphy, personal communication, 2009)
One source remarked that it takes about “3 years” for an inspector to accumulate the
necessary “knowledge, experience, and confidence” necessary to command respect from the
Licensee, and to understand the regulations well enough to competently recognize deficient
performance (GAO, 2007a). Agencies consider the first year to be a training period (GAO,
2007a); in California, the first year of employment for an elder-care LPA includes an average
of 201 hours of training. Subsequent years require 134 hours of continuing training (Barnes
& Sutherland, 2001). CCL’s job announcement for LPAs stipulates no prerequisites for educational or
prior related work experience (CDSS, 2005), yet federal nursing home inspectors are usually
(71%) qualified nurses (Miller & Mor, 2008). Further, limited experience, education, and
difficulties in retaining qualified state SNF surveyors, was associated with, or contributed
to, inconsistent citing of deficiencies, and under citing of deficiencies where actual resident
harm had occurred (GAO, 2003; GAO, 2005; GAO, 2007b). Related to inconsistent
citation patterns, a characteristic appearing to affect how citations are written is how much
interpretation the inspector has to do (Harrington et al., 2001). Another contributor to
inconsistent application of the regulations or under citing deficiencies is the individual LPA’s
work load or difficulty of case load mix. So, if an LPA has many difficult Licensees, or
insufficient time to adequately conduct an inspection, short-shrift can given to the “easier”
facility inspections (GAO, 2007a).
24
Citation Trends
Harrington’s analysis of CMS’ Online Survey, Certification and Reporting (OSCAR)
(Nursing Home) data states the mean number of deficiencies per facility was just under six
for a one-year reporting period (Harrington et al., 2000), yet other sources report higher
numbers of federal citations at about 15.8 per year (Harrington & O’Meara, 2007), with
repeat citations being more than expected (Harrington et al., 2001).
Under Citing
Trends in citation variance (under citing or not citing) has been mentioned elsewhere.
The GAO (2007b) reported that facilities were not receiving sanctions for situations meeting
CMS’ criteria for citation issuance. This same report also suggested CMS’ “fragmented and
incomplete data” sabotaged enforcement efforts (GAO, 2007b). Literature has reported
that inconsistent citation practices are associated with LPA training and education (earlier
mentioned). Inconsistent citation patterns have been identified (GAO,1999), both regionally,
and from state to state (Corrigan, 2003; Harrington & O’Meara, 2007; Miller & Mor, 2008).
CMS benefits from having an extensive, and generally reliable database (OSCAR), which
allows them to review and trend citation patterns (GAO, 2007a; GAO, 2007b), an option not
available to California, as no such database is maintained by the state.
Citation Gaps
Additional issues surround how Title 22 regulations are actually cited on the LIC
809 or LIC 9099 forms. Each Title 22 regulation consists of a five-digit look-up number,
followed by layers of indentured alpha and numeric designations (i.e., CCR, Title 22,
§87577(a)(3)(B), 2010). Frequently LPAs only listed the five-digit look-up number,
omitting the remainder of the regulation consisting of alpha and numeric paragraph and
subparagraph notations. The absence of those paragraph and subparagraph references
limits the ability of researchers to actually pinpoint the deficiency cited. In some cases, one
regulation may consist of 5 to 10 discrete violations. The practice of the LPA citing only
25
the top-level number, limits anyone from knowing which specific regulation is being cited.
The practical effect of this lax protocol eliminates an LPAs ability to cite the Licensee for a
second violation in a 12 month period, if the paragraph, and subparagraph numbers are not
specifically stated; the 2nd violation Civil Penalty rule only applies if the same subparagraph
stated the first time, has been violated again. Without the paragraph and subparagraph
detail, the “2nd violation in 12 months” Civil Penalty cannot be issued, or if issued, can be
successfully appealed.
“Failures to Cite, “ a term coined by this study, refers to situations where the LPA
described an observed deficiency, on the evaluation report (LIC 809, or LIC 9099) but did
not cite the deficiency. This practice has also been observed among SNFs in at least one
state, where the CMS evaluators mentioned the deficiency on the report, intending to call
the deficiency to the attention of the facility, but the facility was not cited for the infraction
(GAO, 2003)
Civil Penalties
Among nursing homes receiving civil penalties (fines for deficiencies), many
are uncollected, and without collection, they cannot be considered a deterrent to poor
performance (GAO, 1999). Frequently, civil penalties are not uniformly applied one facility
to the next (GAO, 2007b). Uncollected and inconsistently applied fines teach Licensees that
“repeated noncompliance carries few consequences,” (GAO, 1999).
Reliability of the Public Record
Society holds individuals, legal entities, and governments accountable, through
written agreements, negotiable instruments, and other written documents. Many facts are
“provable” through production of the authorizing document: marriage is proven with a
marriage license, a current driver’s license establishes the holder’s right to operate a vehicle,
and property ownership cannot be transferred without the requisite Grant Deed.
26
Duranti writes that for a record to be “treated as a fact,” it must be reliable and
must be accorded the strength of evidence and fact. She states that a “reliable certificate of
citizenship [passport] can be treated as the fact the at the person in question is a citizen.” She
further schools us on reliability: “A record is regarded as reliable when its form is complete,
when it possesses all the elements that are required by the...system in which the record is
created for it to be able to generate consequences recognized by the system itself”
(Duranti, 1995).
File incompleteness creates inconsistencies and gaps within the public record,
and diminishes the integrity of data collection and licensure administration. Missing
documentation within the public record is a problem for nursing homes and RCFEs, as
is quickly confirmed by both the United States’ General Accounting Office (GAO), and
California’s Bureau of State Audit office (BSA). GAO report 06-117 states that CMS has
“accuracy and reliability” problems with the underlying data it publishes about nursing
homes on its On-Line Survey, Certification, and Reporting System (OSCAR) website (GAO,
2005). The problem is recurring, as evidenced by a later GAO report noting that “CMS is not
effectively managing the federal monitoring survey database to ensure...offices are entering
data accurately and reliably...” (GAO, 2008). Federal Trade Commission panelists also
expressed skepticism regarding the reliability of consumer information available about both
nursing homes and assisted living (FTC, 2004).
The literature suggests that patterns of incomplete documentation also occurs in
California’s Department of Social Services offices having oversight of licensed child care
facilities; the Bureau of State Audits (BSA) (2009) noted that 100% (emphasis added)
of adoption case files reviewed “...were missing documents that [would] demonstrate
compliance with federal requirements, or the files did not contain evidence of supervisory
review.” An earlier BSA report (2006) revealed approximately 4,100 facility visits during
2002-2004, did not identify the reason for the visit (case management, periodic inspection),
27
noting that changes needed to be made in their documentation system to assure the data could
be used as “a reliable source for assessing [and] meeting statutory visit requirements.”
In a BSA review of CCLD’s regionally reported statistics, the auditor stated the data
was “not sufficiently reliable – we found multiple errors and missing and duplicate data
in our accuracy testing.” (2008). Regarding another survey, the auditors “were unable to
determine the reliability of the data...and concluded that use of the data could lead to an
incorrect” outcome (BSA, 2008). More specifically to CCL’s RCFE files (Flores, Bostrom, et
al., 2008; Flores, Newcomer, et al., 2008), found the public record in CCLD’s RCFE unit to
be so incomplete as to “affect data reliability.”
No literature could be located specifically addressing the reliability of state issued
licensed of any type (drivers, medical, professional), or which quantified the pervasiveness of
incomplete documentation within state agencies.
The Methodology, which follows, describes the breadth, depth, and scope of the file
review; the compilation of many types of data allowed patterns to be analyzed, and revealed.
The literature which has been presented which will assist the reader in contextualizing the
findings of irregularities in CCLD’s licensure, regulation and enforcement of Title 22.
¨
28
Chapter 3
Methods
The purpose of this study was to analyze Community Care Licensing Division
licensure and regulation data for Residential Care Facility for the Elderly (RCFE) in located
in San Diego and Imperial counties. The study is a ten-year (2000 – 2009) retrospective
design; each RCFE file in the sample was reviewed for variables including facility
ownership, organizational type, capacity, special services, financial reports, consistency and
completeness of CCL file documentation, investigations and citations (although many more
variables and data were collected than are presented). This chapter describes the sample,
methods, data collection approach, and data collected. Data were entered into and stored in
an Excel© workbook.
The initial Excel spreadsheets for data collection were based on variables gleaned
from the Flores/Newcomer papers (Flores, Bostrom, et al., 2008; Flores, Newcomer, et al.,
2008). However, once file review commenced, the spreadsheets were expanded to include
additional detail. This study reviewed 348 files randomly selected from the total (705)
RCFE population of licensed facilities in one regional office, drawing exclusively from San
Diego and Imperial counties.
This protocol was submitted to the Institutional Review Board (IRB) at San Diego
State University; because this was a study of secondary data, not involving human subject the
IRB determined that further review was deemed unnecessary.
Sample
The initial population was identified through the statewide list of RCFEs, current
as of January 17, 2009, which was downloaded from Department of Social Services,
Community Care Licensing Division (CCLD) website on January 19, 2009. The statewide
29
list was then sorted by Region; retained data for San Diego and Imperial counties resulted in
a Raw Master List of 705 facilities. This list was sorted by bed count (see Table 3).
Table 3. Stratification by Bed Size
Strata
Bed Capacity
1
1-6
2
7-15
3
16-49
4
50-99
5
100+
Using Excel’s random number generator, each row of data (row = facility) was
assigned a random number. Once sorted by random number in ascending order, the first
50% within each stratum was extracted and moved to the Master List. This procedure was
repeated for each strata until the compiled Master List contained 50% of the facilities in each
of the five strata. Table 4 details the population of San Diego and Imperial County RCFEs,
while Table 5 shows the actual sample obtained.
Table 4. Baseline File Count to Requested Sample
Strata
1
2
3
4
5
Bed
Capacity
Beds
1-6
7-15
16-49
50-99
100+
tOtaLS
3258
615
581
1413
12461
18328
% of
Bed
total
18%
3%
3%
8%
68%
100
Facilities
562
53
19
19
52
705
% of
Facility
total
80%
8%
3%
3%
7%
100
Table 5. Actual Sample File Count by Size Stratification
Strata
1
2
3
4
5
Bed
Capacity
1-6
7-15
16-49
50-99
100+
50%
Sample
281
27
10
10
26
354
actual
Sample
274
28
10
10
26
348
Variance*
-7
+1
0
0
0
-6
* One file moved to Category 2 due to increased capacity, 1 file not provided
(mistake in name), 4 files not licensed at time of review, 1 file withdrawn by
applicant.
30
In this way, the sample was representative of the total distribution in the region. The
baseline of 705 facilities in San Diego and Imperial counties accounted for 8.6% of the total
licensed facilities (8200) in the state, and represented 10.5% (18,328) of the statewide bed
count (174,738).
California Public Records Act (CPRA) Request
File access and review was initiated via a January 29, 2009 California Public Records
Act Request (Appendix B) sent to the Director of CCLD’s Regional Office located in San
Diego. File review began March 2, 2009, and continued through July 7, 2009. In total, 348
(98.3%) of the originally requested 354 requested were reviewed. Six RCFEs on the original
CPRA list were identified as “Closed” at the time of file review, however since each of them
closed within six months (between the original download, and the date of file review), each
was reviewed for all variables.
Although the earlier study established a review cut-off date of 2006, this study
collected data through the 2009 date of file review, believing that emergent patterns may
become more apparent with more, rather than fewer data.
CCLD Protocol
All public files were reviewed and data collected at Community Care Licensing
(CCL) offices in San Diego via pre-scheduled visits. CCLD requires all public file reviews
to be chaperoned by a CCLD employee. Its protocol also requires that the LPA whose case
load includes a particular facility, review the file before it is made available to the CPRA
requestor, to prevent public disclosure of inadvertently misfiled confidential information.
CCLD maintains two files (public and confidential) for each RCFE; the Confidential File is
a separate file folder residing inside the public file, but is removed until the public review is
concluded, at which time they are recombined.
31
File Composition
The RCFE public record uses a specific file protocol. Each file has specific
documents on each side of the file folder (Appendix C). With few exceptions, the file tab
organization was consistent across all files reviewed.
While file organization remained consistent, there was some variation: for example,
most times Job Descriptions and Job Qualifications, if available in the file, were filed
under the Personnel tab. However, they could also be found under Programs and Plans of
Operation. A Hospice Plan of Operation (PoO), if submitted at time of initial application,
would likely be filed under Programs and Plans of Operation, however if the Licensee
applied for a hospice waiver subsequent to licensure, the Hospice PoO may be filed with
the hospice waiver request, with the Fire Marshal Clearance requesting review for nonambulatory status hospice residents, or under the Correspondence tab. It was necessary to
review the entire file for any given piece of information due to the agency’s inconsistent
filing methods. Based on daily work-hour logs, the average review time-per-file was 1.5
hours.
Collection Method
Data was compiled in four Excel worksheets (Appendix D, Tables 27-30): (1) File
Protocol Sheet, (2) Facility List, (3) Staff, and (4) Inspection and Evaluation. Common to
all sheets was the date of the file review, Strata (1 – 5) designation, and the assigned unique
facility number (i.e., T-153).
File Information by Tab
The File Protocol Sheet (FPS) was developed to assure systematic file review. The
FPS contained fields by file organization tab and within that tab, the variable being collected
(Appendix D, Table 27).
32
Facility List
The Facility List consisted of fields for facility name, address, phone number; owner
or licensee name, address, phone number, CCL license number, date the facility was first
licensed, a series of fields capturing the types of services which were licensed, and whether
source documentation was in the file which supported CCL’s authorization of that approval
(Appendix D, Table 28). These variables were selected to provide complete demographic
information about facility ownership and what services the facility was licensed to provide.
Financial Information
Financial Information is a subheading of Appendix D, Table 28. Data was gathered
using the LIC 401 Monthly Operating Statement (see Appendix E), which is housed in
the “Finance” Tab. The form was harvested for the variables of Monthly Revenues, Food
Costs, Insurance, Rent/Lease/Mortgage, Total Operating costs, and Amount of Net Profit
(in dollars). These variables were selected as they were thought to be key indicators of the
RCFE business.
The LIC 401 form is part of the Application package. Once the data is submitted
to CCL, it enters the file, and is neither updated nor revised. The Licensee is required to
estimate the RCFE’s monthly revenues and operating expenses. The applicant estimates
monthly revenue based on a monthly rate(s), multiplied by the number of residents he intends
to house. Estimated expenses include Care & Services (food, supplies, medical and first
aid, transportation), General Administration (salaries and wages, payroll taxes, telephone,
insurance), and Physical Plant (rent, lease or mortgage payments; utilities, repairs). Total
Revenues less Total Expenses yields Estimated Profit (see Appendix D, Table 28).
Monthly Revenues
Title 22 does not require an RCFE to publish or post room rates, nor is a roster of
room rates submitted during pre- or post- licensure, therefore, data harvested from the
LIC 401 is a rare opportunity to examine revenues, room rates, and estimated profitability.
33
An example illustrates how estimated revenues are computed for a 6-bed facility: 2 SSI
residents at $991/each, and 4 residents at $3,000/each - revenues of $13,982 would be
entered on the data sheet.
Not all revenue estimates were that straight forward: if the intended capacity is 75,
the Licensee may base his estimated revenues on less than full capacity (i.e. 75% v 100%);
75 beds @ $3,000 would be $225,000, however because the Licensee based his estimate on
75% capacity, the amount of estimated revenue would be 56 beds @ $3,000 = $168,000,
thereby underestimating his monthly revenue, and reducing the amount he would have to ante
up to meet CCL’s 3-month start-up assets requirement. A variation on revenue estimation is
the Licensee who simply stated total monthly revenue of $168,000 without a formula (room
rate x resident) to support the number. Since actual facility census is variable, the estimates
provided on the LIC 401 provide, at best, a snapshot of the revenues of the facility.
Monthly Room Rates
The methodology for determining Monthly Room Rate varied depending on the
completeness of the data. In easy cases, data was taken directly from the LIC 401 (6 rooms
@ $3,000/mo = $18,000). Where monthly revenues were estimated using two or three
different room rates, the average monthly room rate was derived using the total monthly
revenue as the numerator, and total capacity was used as the denominator. However, when
the Licensee based his revenues on less than full capacity, or just stated a total revenue
amount without itemization, the researcher did not second guess, and simply divided the total
estimated revenues by the stated facility capacity.
Monthly Food Costs
Most LIC 401s had an entry for monthly food costs. The amount stated on Line 7
(Monthly Food Costs) of the LIC 401 was recorded as a monthly amount. Per-resident
monthly cost was achieved by dividing the estimated monthly food costs by the stated
34
resident capacity of the facility. The per-resident-per-day costs were derived by dividing the
per-resident monthly cost by 30.
Staff Information
The Staff variables (Appendix D, Table 29) (job title, number of individuals in that
position, whether speaking English was a stated job requirement, how many LIC 500s were
in the file, dates of each LIC 500 in file) were gathered from two sources: the information
provided by the Licensee on the LIC 500 “Personnel Report” contained most variables, while
review of the Job Descriptions and/or Job Qualifications yielded whether speaking English
was a job requirement. Dates of each LIC 500 in the file were recorded. The variables
selected were thought to be representative of how the facility staffed to meet its caregiving
duties (Appendix D, Table 29).
To assess how many Licensees required English as a job skill, the Job Requirements
and/or Job Qualifications for Caregiver (a required submittal with the Application) were
reviewed for an affirmative statement that English was a required job skill.
Facility Evaluation and Complaint Information
The Evaluation and Complaint Datasheet (Appendix D, Table 30) contains extensive
information from each LIC 809 (Facility Evaluation Reports), and LIC 9099 (Complaint &
Incident Investigation Reports) in the files, and contains approximately 5,300 Excel lines.
Appendix F contains the code dictionary for the Evaluation and Complaint Datasheet (see
Appendix D, Table 30). The two forms are nearly identical in most administrative respects
(Appendix G provides examples of the LIC 809 and the 9099). Variables collected were
date of visit, visit purpose, the LPA, the recorded time in and out of the facility, and outcome
or findings of the evaluation. If findings resulted in deficiencies, each was recorded by
Class (Type A, or Type B), the specific Title 22 regulation violated, and in as many cases as
possible, the verbatim transcription of the LPA’s narrative of the violation (see
35
Appendix D, Table 30). These variables were selected to provide breadth and depth to the
analysis of citation and enforcement patterns, if indeed any patterns could be detected.
Failure to Cite
In addition to the citations issued to a Licensee, the study also captured and coded
deficiencies not cited by the evaluating LPA; these instances were dubbed “Failures to Cite.”
The study was investigating whether there were gaps or failures in the way an LPA
cited a Licensee, therefore deficiencies which were mentioned, and not cited, was considered
an irregularity worthy of capture. Also treated as a failure worthy of capture was the case
where the regulations clearly required a Civil Penalty if the same deficiency was repeated in
a 12 month period, but the LPA didn’t issue the monetary fine.
To summarize, there were two types of Failures to Cite: those observed by the LPA,
documented on the LIC 809 or 9099 in the narrative or advisory notes, but the LPA did
not cite the Licensee for the deficiency, and the 2nd violation of the same subsection of a
regulation within a 12-month period pursuant to §87454(d) (CCR, Title 22, §87454, 2010).
Clearly, there could have been many more deficiencies not cited by the LPA, but in the
absence of evidence on the LIC 809 or LIC 9099, the two types of Failures to Cite were the
only possibilities.
Type 1 Example
The first type of “Failure to Cite” is illustrated by this excerpt from the narrative on a
LIC 809 (Facility Evaluation Report):
“Licensee cannot accept individuals who need a hospice waiver. She [Licensee]
has accepted 2 before she ever applied for a waiver. This cannot happen again.”
The regulations state, “In order to retain terminally ill residents and permit them to
receive care from a hospice agency, the Licensee shall have obtained a facility hospice care
waiver from the Department” (CCR, Title 22, §87716.1, 2010). By retaining two individuals
who required hospice services when, as the LPA noted, the Licensee did not have the
requisite Hospice Waiver, the Licensee was acting beyond the scope of the facility license,
36
and should have been cited under §87110 (a) “A licensee shall not operate a facility beyond
the conditions and limitations specified on the license...” (CCR, Title 22, §87110, 2010).
The LPA did not cite the Licensee. Therefore, this occurrence was noted, and coded as a
“Failure to Cite.”
Type 2 Example
The second type of “Failure to Cite” resulted from the LPAs failure to enforce the
12-month rule pursuant to CCR Title 22 §87454(d) (2010). The LPA cited the facility under
CCR Title 22 §87575(h)(5) (2010) with the following statement of deficiency:
“Facility is pre-pouring medications for all 6 residents a week in advance, from
original containers to daily dispensers.”
Review of other evaluation reports in the file revealed the facility had received a Type
A cite for the identical violation 9 months prior to the date of this deficiency. The earlier
citation, with the current citation, should have triggered a citation under the 12-month rule,
“When a facility is cited for a deficiency and violates the same regulation subsection within
a 12-month period, the facility shall be cited and an immediate penalty of $150 per cited
violation shall be assessed for one day only. Thereafter a penalty of $50 per day, per cited
violation, shall be assessed until the deficiency is corrected.”
If, under the circumstance described, the LPA did not cite License for a Civil Penalty
consistent with CCR Title 22 §87454(d) (2010), the occurrence was coded a Failure-to-Cite
event.
Title 22 Renumbering
During California’s 2008 Legislative Session, the Health and Safety Code, Section
1569 (known as the California Residential Care Facilities for the Elderly Act) was revised
to reorganize the regulations by topic. This reorganization did not affect content, but only
numbering. The reorganization and renumbering of regulations became effective in April
2008; following that date, LPAs used the new numbering.
37
This study’s data was collected from January 1, 2000, therefore 7.5 years of collected
citations used the pre-4/2008 numbering system. To assure consistent analysis of deficiencies
by regulation number, all citations using post-4/2008 regulation numbers were converted
to pre-4/2008 regulation numbers to normalize citation data (approximately 90% of the
collected data reflected pre-2008 regulation numbers). Appendix H contains the Crosswalk
between pre- and post- 2008 Title 22 regulation numbers, derived with the assistance of a
similar document disseminated statewide by DSS/CCL (CCLD, 2008).
38
Chapter 4
RESULTS
The results of this study are presented in four sections: Facility Characteristics, Staff,
Finances, and Enforcement.
Findings related to Facility Characteristics include industry growth, ownership types,
legal entity validation, and RCFE license irregularities.
Staff findings portray what type and in what quantity RCFEs employ skilled medical
professions; culinary, and housekeeping staff, and direct-care caregiving personnel. Also
addressed in Staff Findings is the extent to which English competency is a stated job skill.
Analysis of the LIC 401 – Monthly Operating Statement reveals important findings
regarding average room rates, average resident-per-day food budget, and the profit RCFE
owners report.
Enforcement findings present the Top-Ten Citations issued to Licensees, citation
issuing patterns by LPA, the rate of collection of assessed Civil Penalties, and findings
surrounding Mandatory Non-Compliance Conferences.
Facility Characteristics
Facility Characteristics include industry growth based on annual rate of licensures,
ownership types, legal entity validation and RCFE license irregularities.
Growth in Local RCFE Licensures
The date of licensure of each RCFE was collected from the public record, therefore
it was possible to ascertain the rate of growth in the industry in San Diego and Imperial
counties. 2009 data (n = 12) was eliminated as it represented an incomplete year of data.
Since 2000, RCFE licensures in San Diego and Imperial counties by year, have
mirrored the national trend of growth (see Figure 1). In 2008 (1 Year), 51 facilities were
licensed, nearly a 4 fold increase over the 13 licensures in 2001 (8 Years).
39
New Licensures by Year
Number of Licensures by Year
60
50
40
30
Series1
20
10
0
Years in Business
Figure 1. New licensures by year.
Comparing licensures by Strata for the period 2000 through 2008 (Figure 2) findings
show Strata 1 licensures increased by 300% for the period 2000 to 2008, higher than the 14%
increase in all-size licensed residential care facilities California for the period 2004 to 2007
reported by Mollica (Mollica et al., 2007). Growth among the small RCFE operators was
not specifically corroborated in the literature - only for the industry as a whole.
Ownership and Organization
This study relied on information from three sources to determine ownership type: the
application, the facility profile, and the documents filed in the Organizational Tab. To the
greatest extent possible, the study relied on source information within the file to support all
printed information produced either by the Licensee or CCL.
The application (LIC 200) requires the Licensee-applicant to self-report the type of
facility ownership (a) Individual, (b) Partnership, (c) Non Profit Corp, (d) Profit Corporation,
(e) County, or (f) Other Public Agency. If the applicant checked the “Individual” box, then
the Facility Profile was reviewed to validate CCL had coded the ownership type as stated. If
the application and the facility profile agreed, ownership was coded as Sole Proprietorship.
40
Figure 2. RCFE growth by strata, 2000-2008.
If the applicant checked boxes B through D, the file was searched for organizational
documents supporting the asserted legal entity. Documents taken as evidence of correct selfreport were Partnership Agreements, Articles of Incorporation, or California Secretary of
State Statements of Information. Where supporting documents could not be located in the
file, coding was based on the application information. The organizational composition of
facilities in this sample is shown in Table 6.
Table 6. Facilities by Organizational Type Compared to
Flores, Bostrom, et al., 2008
Organizational type
Sole Proprietorship
Partnership
LLC/LLP
For Profit Corporations
Not-For-Profit Corporations
Flores,
Bostrom, et
al. (2008) %
61.2%
28.6%
10.2%
this
Study %
n
53.4
3.7
13.5
25.3
4.0
186
13
47
88
14
41
These study’s findings are similar to those reported by Flores, Bostrom, et al. (2008),
although Flores, Bostrom, et al. combined all for-profit non-corporations into one percentage.
The for-profit corporation sector identified by Flores, Bostrom, et al. is similar to this study’s
findings, however not-for-profit corporations comprise a significantly lower percentage
(4%) of this study’s facilities, compared to the Northern California sample of 10.2%. These
findings are useful for later determining associations between organization type, and citation
patterns, or other characteristics.
Legal Entity Validation
Entities that are required to register with the California Secretary of State’s (CASOS)
office are Limited Liability Corporations, Limited Liability Partnerships, public benefit notfor-profit corporations, and corporations. The name of each organization reporting itself as
one of these entities was entered into the CASOS’ Business Search portal (kepler.sos.ca.gov)
for two purposes: to validate that the legal entity actually existed, and to ascertain the legal
entity’s status with CASOS. Only organizations in good standing with the CASOS are
authorized by law, to do business in California.
As of 8 January 2010, 12% (18/149) of the legal entities (LLC/LLPs, NFPs and
Corporations) were disqualified to do business in the state, yet each one was licensed by
CCL, and validated by current documents in CCL’s files, their RCFEs were going concerns
(see Table 7).
Table 7. RCFEs Disqualified by CASOS by
Disqualification Type
Reason
No evidence of existence
Suspended (some for over 7 years)
Forfeited
Merged
Canceled
Dissolved
Total
n=
2
9
1
1
3
3
18
%
10%
50%
5%
5%
15%
15%
100%
42
No published literature could be found which had studied the corporate standing of
RCFEs in California or any other state, or could which corroborate these findings.
License
The License is the authorizing document from the state to the Licensee; it is intended
to inform the consumer of the services the Licensee is authorized to provide to the RCFE
resident.
License Content
All RCFE licenses (LIC 203A) identify to whom the License is granted (the
Licensee), the name of the licensed facility, and the bed capacity the facility is authorized
to serve. This study found most (>96%) licenses contained those three components. No
literature was found which looked in detail at the RCFE or AL license in California or any
other state, therefore no corroborating findings can be presented.
License Limitations
The degree to which limits of the license are articulated on the License itself, depends
on the LPA who wrote the license. Once beyond the first three pieces of information
(Licensee name, name of facility, and bed capacity), each license is different, and frequently
inconsistent with the next. Table 8 illustrates this point using verbatim statements taken
from the current licenses of facilities in the sample.
The Collwood Terrace file contains a Dementia Plan of Operation, and maintains
a Memory Care unit, however their license does not reflect state authorization to provide
dementia care. Dementia waivers are no longer required by Title 22, however the state does
require a detailed Dementia Plan of Operation to be presented to CCL if the facility intends
to care for dementia residents (CCR, Title 22, §87724, 2010). Additional requirements
apply to those facilities promoting themselves through advertising, or offering specialized
care environments or units, as providing specialized Dementia care (CCR, Title 22, §87725,
2010).
43
Table 8. Examples of License (LIC 203A) Content Inconsistencies
Facility
License
Cap.
Statement on License
Groups
Served
Collwood
Terrace
Stellar
Care
374602700
200
RCFE/
Hospice
Tri-City
ElderCare
Home
374600976
6
Anne’s
Place
374600462
6
“This license is not transferable and
is granted solely upon the following:
Facility serves 200 Non-Ambulatory
Elderly Residents, Age 60 and
above. 10 of whom may be
Bedridden in Rooms 1001-1010 and
3032. Hospice Waiver Approved for
20 Residents.”
“This license is not transferable and
is granted solely upon the following:
Facility serves Elderly Residents
ages 60 years and above; all of
whom may be non-ambulatory.”
“This license is not transferable and
is granted solely upon the following:
Facility serves six (6) Nonambulatory elderly residents; Age 60
and above.”
Groups or
Info
Missing
Dementia
RCFE/
Hospice
Dementia,
1 Bedridden,
3 Hospice
Waivers
Elderly
4 Hospice
Waivers
Tri-City Eldercare Home file contained authorization to retain 3 hospice residents
(Hospice Waivers), and one bedridden individual; Dementia Care is also provided by this
facility. The license limits stipulated by the state are not reflected on the license.
The file for Anne’s Place contains current documentation from CCL authorizing
Hospice Waivers for 4 residents, however the LIC 203A does not indicate hospice waivers
have been approved for this facility. For some files, determining what approvals had been granted by CCL was highly
problematic. As an example, the researcher found conflicting documents in the file, with
neither document supporting the information printed on the License: the researcher asked the
CCL liaison to confirm the limits of this license (C. Murphy, personal communication, 2009).
The liaison couldn’t answer the question, and referred it to LPA for clarification. The LPA, in
turn, called the Licensee to ask what the agency had authorized.
To the greatest extent possible, the study looked for source documentation to support
the information stated on the license. To this end, the study validated three approvals:
44
Non-Ambulatory capacity, Hospice Waivers and Bedridden approvals; each is separate and
exclusive of the others. Figure 3 pictorially portrays the decision matrix.
Figure 3. Flow chart for Amb/Non-Amb, hospice, bedridden
validation coding.
Two yes/no questions were asked for each: Did the LIC 203A License indicate [NonAmbulatory, Hospice, Bedridden (N, H, B)]? If yes, was there correct documentation in the
file supporting the information on the License?
Coding was:
• 0 = the facility wasn’t licensed for NHB;
• 1 = the facility was licensed for NHB but no documentation was in the file to support
the approval;
• 2 = the facility was authorized to have NHB clients in care, and the file contained
supporting documentation.
• 4 = No findings were possible due to conflicting or missing documentation.
Table 9 presents the findings of this analysis.
The facility population is defined as ambulatory (“a person...capable of demonstrating
the mental competence and physical ability to leave a building without assistance of any
other person or without the use of any mechanical aid in case of emergency,”) (CCR, Title
45
Table 9. Supporting Documentation for CCL Approved Waivers
0 = Not Applicable
1 or 2 = Applicable
If applicable, then . . .
.
1 = No Supporting
Documentation
2 = Documents
Supported Approval
4 = No findings
Total
NonAmbulatory
(n = 348)
2.6%
97.4%
Hospice
Waiver
(n = 348)
35.9%
64.1%
97.4 = 100%
64.1 = 100%
12.9 = 100%
5.3%
8.6%
20.2%
94.3%
89.2%
64.3%
0.4%
100%
2.2%
100%
15.5%
100%
Bedridden
(n = 348)
87.1%
12.9%
22, §87101(a)(6), 2010), or non-ambulatory (“a person who is unable to leave a building
unassisted under emergency conditions... )(CCR, Title 22, §87101(n)(2), 2010). The reason
this distinction is important is that it impacts facility layouts, exit doors, and Fire Marshal
Clearance. The contrast between Ambulatory and Non-Ambulatory is fundamental to
the established protocol and licensure protocol, and may account for the high (94.3%)
documentation of this characteristic; only about 6% of the files do not contain supporting
information for ambulatory status stated on the license, or do not provide sufficient
information to make the determination.
Requests for Hospice Waivers and/or Bedridden approvals frequently come after a
facility has been in business, with the request being triggered by an existing resident’s wish
to “age-in-place” following receipt of a terminal diagnosis. The request appears to be outside
the normal scope of an LPA’s workload, and the process tends to be fragmented (requires a
case management evaluation visit, and a special-request Fire Marshal Clearance). Requests
to retain bedridden residents follow a similar pattern. It is speculated that the out-of-originallicensure sequence partially accounts for the higher rates (10.8% for hospice, and 35.7% for
bedridden) of undocumented (no source document available in the file) approvals for these
special services.
46
No literature was found which studied whether source documents validated the state’s
approvals stated on the RCFE license in California, or for assisted living facilities in any
other state, therefore no corroborating findings can be presented in support of these findings
Dementia Care: No Findings
Knowing which facilities provide dementia care is of singular importance to
consumers because the typical RCFE resident has mild to moderate cognitive impairment
(GAO, 2004; Hawes et al., 2000). This study would have liked to test consistency between
the License and supporting file documentation authorizing Dementia care, but the proposition
was highly problematic.
Before July 2004, a facility could serve dementia clients only with a waiver from
CCL. When the wavier was granted, the License was amended to reflect that the waiver
had been granted. As 3 July, 2004, of Dementia Waivers are no longer required. Facilities
must only (a) submit a Dementia Plan of Operation with its application if it intends serving
cognitively impaired clients, (b) insure its staff has the requisite training hours, and (c)
that certain physical safeguards are in place.
Further, if the facility intends advertising,
and representing itself as expert in the care of dementia residents, additional regulatory
requirements apply as mentioned earlier.
Based on the License itself, it was impossible to reliably ascertain whether a facility
does or does not provide dementia care services. For this reason, no data was collected on
this very important aspect of elder care. No literature was found which studied whether
(a) RCFE licenses correctly reflected the approvals given to the RCFE by the state, or (b)
whether source documents were in the public file to validate whether a Licensee intended of
providing Dementia care in California RCFEs, or AL facilities of any other state, therefore no
corroborating findings can be presented in support of the finding of this topic.
47
Additional Special Approvals: No Findings
Beyond the special approvals addressed, CCL grants, under certain circumstances,
additional approvals to Licensees: locked perimeters, delayed egress systems, and
perimeter fence gate locks (CDSS, 2009). From information available in the public file,
was problematic to determine if, or when, any of special waivers had been granted to any
individual RCFE, as the both the Licenses themselves and the file were silent.
License Correctness
To measure whether the License was correct in all parameters (population served,
special services approved, capacity, Licensee), the each statement on the license was verified
against supporting documentation in the file to determine if the License correctly reflected
the approvals CCL had granted to the facility.
Table 10 depicts how coding was assigned (3 was not used). When the file did not
contain the License, validation attempts were unsuccessful.
Table 10. Coding of License Correctness
Code 1
Code 2
Code 4
Code 5
A. License reflected
approvals and
statements, but
supporting
documentation was
not found in file
OR
B. License did not
reflect approvals or
statements for which
supporting document
was found in file
1-to-1 congruence
between statements on
License, and
documentation in file.
License and or file
documentation was
conflicting or
ambiguous
No License in file.
Findings from this validation effort are shown in Table 11. 40.5% of the files
reflected a 1-to-1 congruence between statements and approvals on the License, and
supporting documentation in the file. The remaining 59.5% of files Licenses were incorrect
(No), conflicting or ambiguous (No Findings) or missing (No License in File).
48
Table 11. License Content
Matched Supporting Documents
in File
Finding
No (1)
% (n= 348)
44.5 (155)
Yes (2)
No findings (4)
40.5 (141)
12.9 (45)
No License in File
2.0 (7)
No literature was found which studied whether the Licenses in California RCFEs, or
AL facilities of any other state, correctly reflected the content and statements made on the
License, therefore no corroborating results can be offered in support of the findings presented
here.
Staff
Title 22 requires the Licensee to submit a LIC 500 at the time of application, and
whenever personnel changes occur, or at least once a year. Of the total sample of 348 files,
6.8% (n = 24) did not contain LIC500s. All findings, unless otherwise specified are based on
the remaining sample (n = 324) of files which contained LIC 500s.
RCFEs are “non-medical housing alternatives,” despite their resident case mix; others
have found residents have many of the same deficits of skilled nursing homes residents
(Burger et al., 2000; Harrington et al., 2000; Schaffner, 2008). Title 22 allows RCFEs to
serve residents with chronic “incidental medical conditions”; these conditions, as defined by
CCR Title 22 §87575 (2010), include oxygen administration, injections, diabetes, indwelling
catheters, bedridden residents, residents requiring intermittent positive pressure breathing
machines, and stages 1 and 2 decubitus ulcers. Title 22 requires no skilled medical staff be
employed by the facility, even if an RCFE populates its entire capacity with residents having
any of the allowed medical conditions.
49
To measure how many RCFEs employ skilled medical professionals absent an
affirmative requirement of Title 22, the LIC 500 was inventoried for those job categories.
Findings are summarized in Figure 4.
Specialized Staff Employed by RCFEs
100.00%
Frequency in Percent
80.00%
60.00%
Employed - Yes
40.00%
20.00%
11.70%
4.30%
8.60%
10.10%
9.50%
LVC/LPNs
Culinary
Housekeeping
0.00%
RNs
CNAs
Job Categories
Figure 4. Specialized staff employed by RCFEs.
Skilled Medical Professionals
The majority of sample facilities (n = 324) reported not employing Registered Nurses
(88.3%), Certified Nurses Assistant (CNA) (95.7%), or Licensed Vocational Nurse/Licensed
Practical Nurse (LVN/LPN) (91.4%). This finding is consistent with the non-medical
housing alternative model promulgated by the regulations. Conversely, between 4% and
11% of facilities did report employing (as non-contracted staff) one or more types of skilled
medical professionals.
Ancillary Staff: Kitchen, Culinary and Housekeeping
Literature reports that many staff members wear many hats, and are responsible
for housekeeping, and culinary tasks as well as caregiving. To measure what percentage
50
of facilities in this sample employed these skill categories, the LIC 500 was reviewed for
personnel in these jobs. Findings (see Figure 4) show that 89.9% of the facilities do not
employ kitchen or culinary staff, and 90.5% do not employ housekeeping staff.
Caregivers
Because caregivers counts reported on the LIC 500 range from 0 to 64, the job class
was categorized, then cross tabulated by Strata. Findings are shown in Table 12. Of the
entire caregiver sample 47.4% (n=326) fall into Category 2 (2 – 4 caregivers [cg]) by Strata 1
facilities. The shading in Table 12 emphasizes the concentration of caregivers in Categories
2 and 3, in Strata 1 facilities. The number of caregivers is positively correlated with facility
size strata as confirmed by a Pearson Chi-Square (χ² =2.644, df = 32, p = .000).
Table 12. Caregivers (by Category)/Per Facility/By Strata
Category
Strata 1 Strata 2 Strata 3
Strata 4
(1 – 6)
(7 – 15) (16 – 49) (50 – 99)
(Range)
Category 0
2.6%
.3%
.0%
.6%
(0 cg)
Category 1
5.7%
.3%
.3%
.0%
(1 cg)
Category 2
47.4%
3.7%
.3&
.3%
(2 -4 cg)
Category 3
19.5%
2.3%
.6%
.0%
(5 – 10 cg)
Category 4
1.1%
.6%
1.1%
.3%
(11 – 14 cg)
Category 5
.0%
.0%
.0%
.6%
(15 – 30 cg)
Category 6
.0%
.0%
.0%
.6%
(31 -40 cg)
Category 7
.0%
.0%
.0%
.0%
(41+ cg)
Incomplete or
2.9%
.6%
.3%
.6%
Missing Data
Strata 5
(100 +)
.3%
.0%
.3%
.3%
.9%
2.3%
.9%
.3%
2.3%
Staff: Total by Strata
Total staff for each facility was recorded. Because reported Total Staff ranged
between 0 and 409, numbers were categorized to better show trends in staff size.
51
Table 13 shows that Strata 1 has the highest frequencies of smaller staff
(Categories 1, 2) with the majority of Strata 1 facilities (n=176) reporting staffs of between
1 and 5 persons to perform 24/7 caregiving. Total staff is positively correlated with facility
size (χ² =6.947, df = 160, p = .000).
Table 13. Total Categorized Staff by Strata
Total
Strata 1
Strata 2
Strata 3
Employee
(1 – 6)
(7 – 15)
(16 – 49)
Count
1–5
176
10
1
6–10
80
11
2
11-20
9
4
4
21–50
0
0
1
51-75
0
0
0
76-99
0
0
0
100+
0
0
0
265
25
8
Strata 4
(50 – 99)
Strata 5
(100 +)
Totals
2
0
0
3
2
0
1
8
0
0
0
8
5
1
4
18
189
93
17
12
7
1
5
324
English Speaking Caregivers
Chapter 2 cites literature that the typical resident of assisted living is a widowed
white woman over 75 (with a mean age of 86) – and by extrapolation from census data, for
at least 60% of them - English is their first language. Title 22 does not stipulate a definitive
requirement that facility personnel speak fluent English. CCR Title 22 §87565(d)(3) (2010)
states staff must have “Skill and knowledge required to provide necessary resident care and
supervision, including the ability to communicate with residents.” The Assisted Living
industry recognizes these words as a tacit requirement to hire workers who speak English
(Nickerson, n.d.).
Table 14 presents the findings of this study: one in six, or 16.7% (n = 58) had job
descriptions and/or job qualifications in the file which specifically stated caregivers were
required to speak English (i.e. excerpts from documents in files: “Caregivers are required to
communicate in English,” “required to read, write and communicate in English,” or “Ability
to effectively communicate in English with all staff at an 8th grade proficiency”), while
52
Table 14. Requirement for English Language Competence
Affirmative Requirement for
No Requirement for English
English Language Competence
Language Competence
16.7% (n=58)
72.7% (n = 253)
No Data
10.6% (n =37)
another 72.7% (n = 253) files had job descriptions and/or job qualifications that were either
silent on the topic, or contained an “almost” requirement (i.e. excerpts from documents in file
“read, comprehend, and write English,” or “able to read, write and understand English”). The
remainder, 10.6% (n = 37) files had no job descriptions and/or job qualifications in the file.
File Completeness
By regulation, an LIC 500 Personnel Report should be submitted whenever there is
a personnel change, or a minimum of one per year. All files were reviewed for this form;
93.4% contained LIC 500 forms. This finding is lower than the 99.3% of found in the Flores,
Newcomer, et al. (2008).
Detailed review of the LIC 500 found that 19.3% of files contained a Report dated
within twelve months from the date of the file review, and the remaining 80.7% did not have
a current (within 12 months) Personnel Report in the file. These findings are nearly identical
with those reported by Flores, Newcomer, et al. (2008): 20% of the files had reports 12
months or newer, while in 80% of their sample, the LIC 500 was more than 12 months old.
The frequency of LIC 500s in the file were analyzed against how many years the
facility had been in business; that is: if the facility had been in business for 3 years, it should
have a minimum of three LIC 500s in the file. If so, the researcher coded the data as 3/3
or 100%. In contrast, if the facility had been licensed for 8 years, but only had 1 LIC 500
report in the file, the “percentage complete” was 12.5%. Data was compiled, coded, and
categorized into groups, for analysis. Table 15 summarizes the findings of completeness of
the file for the LIC 500 document. Approximately 25% of the files had a one LIC 500 for
each year of business, while nearly 72% were significantly incomplete, ranging from a low of
none in the file for the last ten years of licensure, to having files that were 75% complete.
53
Table 15. File Completeness of LIC 500
Personnel Report
Categories of
% of LIC 500 File
Completeness
Completeness
100%
24.7%
75% - 99%
3.5%
50 – 74%
20.7%
25% - 49%
20.1%
0 – 24%
31%
Incomplete data was analyzed by Strata as shown in Table 16. The larger facilities
tended to have more missing LIC 500s as a percentage of the total category. Larger facilities
tended to have more missing LIC 500s as a percentage of the total category.
Table 16. Missing LIC 500s by Strata
Strata 1
10
Files with No LIC 500
276
Total Files
% of Category with
4%
Missing Data
Strata 2
2
27
Strata 3
1
9
Strata 4
2
10
Strata 5
8
26
7%
11%
20%
31%
Finances
Of the total files reviewed (n = 348), 97 predated January 1, 2000, and were removed
from the analysis. From the remaining 251 files, another 3.5% (n = 9) had no LIC401
form in the file, and 3.5% (n = 10) contained substantially incomplete data. Data from the
remaining 232 files were used for analysis. All financial variables were analyzed within the
five Strata, and are presented in Table 17.
Monthly Revenues and Per Day Rates
A primary source of income in RCFEs is derived through monthly room rent. Room
rates are largely market driven, and public price lists of room rates are not required by
Title 22. Data for analysis was obtained consistent with methods described in Chapter 3.
Findings regarding monthly revenues, and calculated mean monthly room rental rates
(Table 17, Section A, Item 2), fall within the range cited by the GAO (GAO, 2004): between
54
Table 17. Summary of Financial Findings, by Strata, by Variable
Strata 1
Strata 2
Strata 3
Strata 4
Strata 5
(1 – 6)
( 7 – 15)
(16 – 49)
(50 – 99)
(100+)
(n = 197)
(n = 11)
(n = 7)
(n = 4)
(n = 13)
A. REVENUES
1. Mean Monthly
$14,795
$22,771
$68,731
$270,068
$521,471
Revenues
(Range
(Range
(Range
(Range is
($69,988 to
$2,800 $6,008 $30,000 $212,835 - $1,343,011)
$38,000)
$42,000)
$125,845)
$409,471)
2. Mean Monthly
$2,555
$2,020
$2,689
$4,233
$3,424
Room Rate
(Range
(Range
(Range
(Range is
(Range
(Average/30)
$904 $858 $1,932 $4,000 $909 $6,333)
$2,800)
$5,250)
$4,817)
$6,882)
$85/day
$67.33/day
$89.63/day $141.10/day $114.13/day
B. FOOD
1. Mean Monthly
$1,164
$1,581
$3,748
$6,279
$31,222
Food Costs
(Range $30
(Range
(Range
(n = 3)
(Range
- $3,795)
$600 $2,000 (Range
$3,708 $3,000)
$6,000)
$4,891 $140,591)
$13,682)
2. Mo. Food
7.8%
6.9%
5.4%
2.3%
6%
costs as a % of
(n = 3)
Revenues
3. Average
$6.64
$5.21
$4.76
$3.82
$5.50
Food $$ Per Day
(n = 196)
(Range
(Range
(n = 3)
(Range 81
Per Person
(Range .82
$1.52 –
$3.13 (Range
cents cents $8.22)
$6.57)
$2.87 –
$26.13)
(Mean Mo Food
$20.80)
$4.73)
Cost/capacity/30)
C. PROFIT
Average Monthly
+31%
+34.5%
+23.24%
+14.92%
+13.74%
% Profit as a %
(Range (Range -1%
(Range
(Range .4% (Range -9%
of Revenue
12% to
to +53.6%
+12% to
to 51.54%)
to +40.9%
+72.2%)
+40.3%
$1,020 and $4,429 but trending towards the second quartile of the range. These findings are
higher than those reported by Curtis (Curtis et al., 2000), and 2 out of 5 Strata report higher
than the average rates reported by Newcomer (Newcomer & Maynard, 2002). Reasons for
the trend towards higher rates could include unadjusted or non-normalized dollars, or the
geographic factor reflecting higher realty and cost of living in Southern California. The
ranges identified with each Strata indicate the some facilities may take SSI residents.
55
Food Costs and Per Resident Food Costs Per Day
Average monthly food allowances by Strata are shown in Table 17, Section B, Item 1.
While averages are useful, the more troubling trends can be seen in the lower ends
of the Strata ranges: In Strata 1, one facility estimated spending $30 on food per month for
a resident. The bottom end of the range for Strata 2 was $600. Assuming a low census (7),
$600/7 = $85.71 per month per resident. Assuming full capacity of 15, the per month per
resident food allowance is $40/month ($600/15).
Economies of scale exist in both the purchasing and preparation of food in any size of
assisted living facility, however even the more generous daily averages of $4.76 (Strata 4), to
the enriched $6.64 (Strata 1) must be viewed in the context that the amounts are overstated
by the number of staff eating along side paying residents. (Staff eat at the facility as part of
their compensation, and the facility is allowed to decrement their wages by the value of the
meals they consume.)
Average per-resident-per-day food allowances are compared against averages given in
the USDA’s Daily Food Plan (USDA, 2009), and presented in Table 18.
Table 18. The USDA Low-Cost Per-Day Food Plan Compared to the Range of Costs for
RCFE, within each Strata
USDA
Daily Food
USDA Low-Cost Food Plan
Allowance Range
$4.19 to $4.92
Strata 1
Strata 2
Strata 3
Strata 4
Strata 5
Range
$0.82 to
$1.52 to
$3.13 to
$2.87 to
$0.81 to
RCFE
$20.80
$8.22
$6.57
$4.73
$26.13
$6.64
$5.21
$4.76
$3.82
$5.50
Average
Table 18 shows that Strata 4’s average of $2.86/per resident per day is considerably
lower than the USDA Range of Low-Cost Daily Food Plans. While the averages for the
other Strata are within, or exceed, the USDA’s Low-Cost Food Plan Allowance ranges,
the problem is becomes apparent in the low ends of each Strata’s range - the question is
irresistible: can adequate food quantity and nutrition be provided to RCFE residents on
56
$0.82/day, or $1.52/day? The concern here is that Licensees would report, and perhaps
actually feed, residents on unrealistically low daily food budgets.
Another measure of food costs was obtained by calculating the percentage of the
food budget against the total estimated monthly revenues of the average RCFE by strata.
Averaging all Strata, monthly food estimates represent less than 6% of the total operating
expenses of a facility. This is important to note, because the industry frequently singles out
food costs (Personal Notes, 2009) as an area for cutting costs and saving money. In this
context, Beverly Enterprises’ reported profits of $5.28 of per-resident-per-day (Harrington et
al., 2001), is higher than 3 out of 5 of the per-resident-per-day averages found in this study.
Profits
Findings show that 96% of this study’s sample of RCFE are profit-making enterprises
(see Table 6, p. 40) . That RCFE owners clearly expect to make a profit, is suggested by
Table 17’s Section C (p. 54), where average monthly profit (total revenues minus total
expenses) by Strata shows the overall range of monthly profits between -12% to +72.2%.
The number of facilities in the negative-to-zero range comprised 1.4% of the total sample.
Two of the five Strata average profitability rates are similar to the industry-reported
benchmark of operating profit margin of 33% (Moore, 2001).
Enforcement
The total individual visits to facilities recorded in this sample, made during the 20002009 period, were 2,266 (visits are for annual, random annual, complaint, investigation, case
management, non-compliance conferences). If a visit resulted in five citations, each citation
was placed on a separate line coded with the facility identification (ID) number, the LPA,
date, reason for visit, citation type, and regulation cited. Thus, if an LPA issued 25 citations
on a single visit, the single visit would expand from one line on the spreadsheet to 25. Thus
2,266 visits expanded into total recorded discrete actions of 5,254; out of these, there were
57
3,313 citations outcomes, and 1,941 actions that did not result in citation issuance. Table 19
delineates the findings of these enforcement actions.
Table 19. Summary of Discrete LPA Actions
Total Recorded
# of
Outcome Types
Discrete Outcomes
Outcomes
All Causes
5,254
All Types
Zeros
(substantial
compliance, or other
non-citing actions,
Failures to Cite)
1941
1687 events not
resulting in
citations.
254 Failures to
Cite
Citations Issued
3,313
2,146 Type A
959 Type B
208 Not Stated
Missing Documents
(includes only those
instances where a
document was
mentioned but did not
appear in the file)
113
Unknown
Descriptions of
Outcome Types
As Described Below
32 substantiated complaint not
cited
543 Substantial compliances
42 management related visits
11 Denied Entry Visits
271 Unfounded Complaint
Actions
293 Prelicensure Deficiencies
174 No statement of Findings
225 Licensure approved during
visit
96 Missing Documents
6 Substantial compliance with
failures to cite
248 Failures to Cite
2,779 Citations issued during
LPA visit
17 where evidence of the citation
was indirectly obtained, but the
actual issuing document was not
in the file (Note: this 17 counts
in the totals of both citations, &
Missing Documents below)
517 Substantiated complaint
with cited deficiency
96 Missing Documents where
evidence in file mentioned a
document not in the file.
17 Where evidence of the
citation was indirectly obtained,
but actual issuing document was
not in the file (Code 211)
Citations were recorded by type: Type A (Severe – immediately jeopardizing resident
health or safety), Type B (deficiencies not placing residents in immediate jeopardy as to
58
health or safety), or Failures to Cite. LPA actions resulting in substantial compliance, or
other non-citing circumstances, were coded 0.
The significant findings of these descriptives are the “Failure to Cite” category of
non-citation (n = 254), and “Missing Documents” (n = 113). SNF literature discussed state
surveyors not citing conditions subsequently cited by Federal surveyor when in the same
SNF (Chapter 2, Part 4). It is likely these Failure To Cite instances are similar to prior
observations. The Failure to Cite was coded in 254 instances for one of two types of failures:
When the LPA described the deficiency in the narrative on the LIC 809, or LIC 9099, but did
not cite the Licensee; and when the LPA failed to cite the 2nd violation of the same regulation
in a 12 month period – which should have resulted in a Civil Penalty. While the percentage
of the total citations is small (7.7% [254/3,313] it appears LPAs exercised unexplained
discretion in citing for regulatory infractions.
The second descriptive of interest is the Missing Documents (n = 113) finding. This
finding represents 3.4% [113/3,313), and its occurrence means that 113 discrete inspections,
complaint and incident investigations and case management actions are not available for
review by the public. The Missing Document category included those instances where
another document in the file made reference to the missing document, and a separate
search of the file did not yield the named document. The other type of instance coded as
Missing Document, was where the file contained a document fragment (i.e. of an 8 page
LIC 809 facility evaluation, only page 3 was in the file.) This finding was not specifically
corroborated in the literature, though Newcomer and Flores note that CCLD’s files were very
incomplete (Flores, Bostrom, et al., 2008; Flores, Newcomer, et al., 2008), the nature of the
incompleteness was not indicated.
Citations By Type
The Citations were coded as A, B, or Unknown Severity (Unk Sev). Type A citation
issuance leads Type B issuance by about 2.25 to 1. Citations not designated by the LPA as
either A or B, represented about 6.3% (n = 208) of the total citations issued (n = 3,313). In
59
terms of citation type by Strata, small 1 – 6 bed facilities received the highest number of
Type A’s, followed by Strata 2. Table 20 presents citations by severity for each of the five
strata. That Strata 1 received 63% of all Type A citations is not surprising, given that Strata
1 facilities comprise about 80% of the total RCFE population. The more revealing analysis is
provided in Table 21.
Table 20. Citation Types by Strata
Citations (n = 3313) by
Severity
Type A
Type B
Unk Sev
2,146
959
208
64.8%
28.9%
6.3%
64.8% = 100% →
28.9% = 100% →
6.3% = 100% →
Strata
1
Strata
2
Strata
3
Strata
4
Strata
5
Sum
63.4%
59.7%
66.8%
21.6%
22.9%
18.8%
4.8%
5.2%
1.0%
2.4%
4.4%
4.3%
7.8%
7.8%
9.1%
100%
100%
100%
Table 21. Type A Citations per Strata Beds
Beds in
Sample
Strata 1
Strata 2
Strata 3
Strata 4
Strata 5
Total
1629
307
291
706
6231
9164
Type A
Citations
%
(n = 2146)
63.4
21.6
4.8
2.4
7.8
100%
Citation
#
Citation to Bed Ratio
1,361
464
103
51
167
2,146
1: 1.19
1: 0.66
1: 2.8
1: 13.8
1: 37.3
—
Table 21 reveals that Strata 5 facilities receive 36 times fewer citations than does a
Strata 1 facility. Also, Strata 5 facilities receive nearly 3 times fewer citations than Strata
4 facilities; Flores observed a related, thought not quantified, pattern – reporting that larger
facilities (100+) have lower rates of citations, while smaller facilities receive higher rates of
citations (Flores, Newcomer, et al., 2008).
Citations by Regulation and by Strata
This sample collected 3,313 citations during the ten-year period (2000-2009). The
3,313 citations represented eighty separate Title 22 regulations. Table 22 summarizes the
60
Table 22. Top Ten Citations, by Regulation
Regulation
Number
# of
Citations
% of all
Citations
Regulation Title
Types of Deficiencies Cited
Medication errors: (incorrect, missed,
expired, inappropriate, not logged, incorrect
storage.
Medical Care: inappropriate, incorrect, lack
of, neglect, didn't obtain, failure to observe.
First Aid Training: no training, inadequate
training, expired certificate.
Dementia Care: lack of, inappropriate,
inadequate staff training, insufficient
staffing, resident in need of higher level of
care.
Water temperature; dirty facility, pervasive
urine odor; bathroom safety - rails; physical
disrepair; broken furniture; insufficient
furniture.
§87575
n = 526
15.9
Incidental
Medical &
Dental Care
§87724
n = 377
11.4
Care of Persons
with Dementia
§87691
n = 325
9.8
Maintenance &
Operation
§87565
n = 191
5.8
Personnel
Requirements
§87566
n = 188
5.7
Personnel
Records
§87219
n = 146
4.4
Criminal Record
Clearance
§87576
n = 138
4.2
Food Services
§87577
n = 130
3.9
Personal
Accommodations
& Services
§87692
n = 130
3.9
Storage Space
Unlocked or accessible toxics; sharps and/or
firearms. Storage of flammables near flame.
§87570
n = 119
3.6
Resident Records
Resident records: incomplete, missing, offpremises, no roster.
Insufficient staff; non English speaking staff;
no or inadequate staff training.
Staff records missing; files unavailable for
review; file retention; no TB test or test
results
Uncleared personnel in facility and other
DOJ related matters.
Insufficient food stores; inadequate portions,
unsafe food practices (storage, thawing,
disinfecting, labeling).
Inadequate personal accommodations and
services; sleeping in common rooms; no
blankets, bed pads, linens; bedrails, postural
supports.
ten most frequently cited regulations in rank order (CCR, Title 22, n.d.). Figure 5 takes the
same ten citations and allocates them by Strata. Table 22 and Figure 5 taken together show
patterns of citation by both Regulation and Facility Size.
Reviewing Table 22 first, nearly 16% of all citations issued were for the CCR Title
22 §87575 (2010) – Incidental Medical and Dental Care, which encompasses medication
errors, medical care, and neglect. The frequency this regulation is cited is telling: California
RCFEs may retain residents having many chronic medical conditions (oxygen IPPB
machines, bedridden, diabetes, indwelling catheters), yet, when coupled with the absence of
61
Top Ten Citations by Strata
400
350
300
Strata 1
Strata 2
Strata 3
Strata 4
Strata 5
250
200
150
100
50
0
87575
87724
87691
87565
87566
87219
87576
87577
87692
87570
Cited Regulation (Top Level)
Figure 5. The top ten citations by strata.
regulatory requirements requiring any type of skilled medical professional to be on staff, this
finding cannot be surprising.
The second most frequently cited regulation, representing 11.4% of all citations
issued, addresses a variety of dementia care issues. The regulation is quite long, and has
many subparts, of which many are discrete violations. As mentioned earlier, this finding,
while helpful, is not nearly as useful as it could be if LPAs routinely cited paragraph and
subparagraph. Such enhanced precision would allow researchers and consumers to have
greater understanding of the specific infraction, and would allow assessment of the quality of
care risk presented by the deficiency.
To round out the top three citations, Maintenance and Operation is the third most
frequently cited regulation, with a finding of nearly 10% of all citations written. Recall
the Staffing findings of Strata 1 and 2 facilities: data revealed that most 1–6 and 7–15 bed
facilities have average total staff of between 5 and 9, and do not employ housekeeping,
culinary, or laundry staff, but these individuals are responsible for caregiving, as well as
for performing the full range of domestic chores. The implication of this finding is that
facilities cited for deficiencies such as dirty premises, pervasive urine odors, bathroom safety
62
issues, walkways littered with trash cans, abandoned potted plants and dog feces, do not
have sufficient staff to both provide resident care and supervision, and keep the house clean
and safe for residents. Another implication of this finding relates to the ramifications of the
amount of profit being earned by the Licensees: with such generous bottom-lines, it raises
the question why Licensees would allow their residents to live in a property not properly
maintained, especially when the estimated profits suggest adequate earnings to accommodate
modest expenditures on maintenance and housekeeping services.
Top Ten Regulation Citations by Strata
Using the same Regulation Numbers, coded to the same Regulation Titles provided in
Table 22 (p. 60), Figure 5 illustrates the finding that Strata 1 facilities receive more citations
than do the larger facilities (also shown in Table 21, p. 59). The findings suggest that the
trend of more citations among Strata 1 facilities is either an indication of the deleterious
effects of low staffing patterns throughout that segment of the RCFE demographic, or that
LPAs spend more time in these facilities (based on the finding that smaller facilities receive
37 times the citations than the largest facilities). Figure 5 also dramatically suggests that
Strata 1 facilities receive many more times the number of citations for Regulation 87575 –
Incidental Medical and Dental, which encompasses medication errors, inappropriate medical
care, or neglect (CCR, Title 22, §87575, 2010). That finding is again juxtaposed against the
staffing patterns for Strata 1 facilities, where few employ skilled medical professionals to
assist with residents having chronic medical conditions as allowed by the regulations.
Civil Penalties
According to CCL’s Evaluator’s Manual, Civil Penalties are assessed for many
reasons: immediate penalties for violations and noncompliances with Criminal Background
checks, failure in having non-fingerprinted staff working at the facility, and failing to have
Criminal Background checks transferred from one facility to a new facility. Other reasons
63
for Civil Penalties are the facility failing to make timely corrections of deficiencies, or
receiving a second violation of the same regulation within a 12-month period.
In this sample, 222 Civil Penalties were found in the files. They were issued (data
was taken from assessments or invoices) for amounts ranging from $50 to $4,000, and totaled
$63,300. The number of Civil Penalties (6.7%, n =222 [222/3313]) is slightly higher than
reported by Flores, Bostrom, et al. (2008), where Civil Penalties comprised 4.4% (n = 168) of
their sample.
The per-event assessment in this study was between $50 and $150, either per event,
or per day, depending on how the LPA had written the assessment. Table 23 shows that
25.5% of the penalties were collected.
Table 23. Civil Penalties Assessed vs. Paid
Amount of
Verified Paid
% of
Civil Penalties
Civil Penalties
Collection
Assessed
$63,300
$16,182
25.5%
Fines were considered paid with file evidence of a CCLD statement showing a zero
balance, a CCLD handwritten receipt, or a copy of the check paying the assessment. This
is not to say the state collected only one-quarter of the fines it assessed, but rather, that only
25.5% could be verified from file content.
Time between Invoice and Payment could not be measured due to absence of
payment information, however one file revealed a letter to the Licensee advising that since an
outstanding Civil Penalty was over 24 months in arrears, the matter was being referred to the
Franchise Tax Board for collection.
Civil Penalties were assessed for a variety of reasons including failures to have
(a) criminal background checks done on employees before they begin working in the RCFE,
(b) the criminal background check of the individual associated to the facility, (c) Plan
of Corrections completed by specified due dates, or incurring a 2nd violation of the same
64
regulation in a 12 month period, etc. Findings revealed that 32.8% of all Civil Penalties
were related to Criminal Background Clearances, Criminal Background Associations
and Fingerprinting requirements. Unknown reasons (due to missing or incomplete file
documentation) for issuance accounted for 6.3% of Civil Penalties. Of all Civil Penalties,
60.9% were issued for other reasons including 2nd violation of the same regulation within a
12-month period, or failure to have corrections made in a timely manner.
Errors in Assessing Civil Penalty Amounts
Two observations, albeit un-quantified, were made regarding CCL’s incorrect
assessment of civil penalties. The first type of error occurs when an LPA cites a Licensee,
for example, for five 2nd violations of the same five deficiencies within a 12-month period.
Each of those 2nd violations carry a individual $150 Civil Penalty. When the invoice for that
assessment was found in the file, instead of reading $750 (5 x $150), the facility was assessed
one $150 penalty. The CCL liaison was questioned about this observed practice; according to
the researcher’s personal log, the individual admitted CCL had been “doing it wrong.”
A second type of Civil Penalty assessment error was observed when the LPA cited a
$150 immediate penalty, with a $50/day continuing penalty until correction is made. Due to
the incomplete condition of the file, it was impossible to ascertain when the correction had
been made, to know what the final Civil Penalty assessment amount should be. Frequently
when the invoice was found corresponding to the original assessment, the $50/day continuing
penalty did not appear, the invoice simply stated $150.
These findings are not quantified because there was insufficient information in
the files to inventory the number of times these errors were made. Further, no published
literature could be found which addressed whether these incorrect patterns of assessment
occurred in other CCL offices statewide.
65
Noncompliance Conferences
Of the total of visits compiled in this study (2,266), 9.7% (n = 22) of the facilities
received mandatory non-compliance conferences. Of the 22 individual facilities who
attended these mandatory conferences, 50% (n=11) of the files did not contain a NonCompliance Summary. Noncompliance Conferences occurred with greater frequency in
Strata 2 and 3 facilities, as shown in Table 24.
Table 24. Noncompliance Conferences as Percentage of Strata
Strata 1
Strata 2
Strata 3
(1 -6)
(7 -15)
(16 – 49)
A. Facilities with
Noncompliance
11
6
2
Conferences (NCC)
B. NCC as a % of
4%
21.4%
20%
Strata
C. Missing
5/11 =
Noncompliance
2/6 = 33% 1/2 = 50%
45.5%
Summaries
D. Total Facilities in
274
28
10
Strata
Strata 4
(50 – 99)
Strata 5
(100+)
0
3
0%
11.5%
0
3/3 =
100%
10
26
The finding that 11.5% of the Strata 5 facilities received noncompliance conferences,
given the earlier findings that they receive nearly 37 times fewer citations-per-bed than
Strata 1 facilities, is puzzling. Table 25, Line C also shows that noncompliance
summaries of 100% of Strata 5 facilities were missing, and overall, 50% (11/22) of the 22
noncompliance summaries were missing from the file.
Figure 6 graphically presents the total number of citations and visits received by
the 22 facilities who received noncompliance conferences. Findings show eight facilities
had cumulative citations of over 40 (range 42 – 78). Two of those facilities had cumulative
citations of 77 and 78 respectively, and received a CCL visit once every 6 months, and once
every 3.7 months, respectively. The anomalies are the two facilities each having fewer
than 10 citations, but still receiving mandatory noncompliance conferences. Collectively,
these findings suggest that CCL gives the Licensee generous time to correct and reverse
66
Table 25. Number of Citations, by Type, by Licensing Program Analyst
2.
Type B
Citation
3.
Unknown
Class of
Citation
C.
Failure
to Cite
Citations
Per Month
(B/Total
Months in
SD Office)
164
8
15
5
2.3
122
101
21
0
6
1.7
86
40
43
3
16
1.4
52
159
119
24
16
16
2.3
59
38
21
16
1
0
0.4
181
255
122
116
17
27
2.5
103
1219
862
324
33
40
11
LPA
ID
Total
Months
in SD
Office
Total
Actions
(A+B+C)
A. NO
Citations
B. Total
Citations
(1+2+3)
1.
Type A
Citation
3
81
242
50
187
4
70
197
69
5
60
289
187
8
70
227
9
87
97
16
101
463
28
111
1362
29
70
149
50
98
66
26
6
1
1.4
32
63
149
63
76
23
50
3
10
1.2
Facility Noncompliance Conference Characteristics
21
19
Individual Facilities
17
15
13
Total Visits/Review Months
Total Citations for Facility
11
9
7
5
3
1
0
20
40
60
80
100
Frequency of Citations & Visits
Figure 6. Facility noncompliance conference characteristics.
noncompliances before using the mandatory conference as a method to exact and maintain
compliance.
Licensing Program Analyst Citation Patterns
This study assigned Licensing Program Analyst (LPA) codes to each CCL evaluator
who performed a facility evaluation or complaint investigation. The same LPA code was used
67
for all other reports written by the same evaluator. In all, the work of 35 discrete evaluators
was reviewed and coded. Some individuals appear to have been brought in from other CCL
offices to alleviate temporary staff shortages, while others have been in the San Diego office
for the ten-year period of the study. The number of individual reports written by an LPA
ranged from 1 to over one hundred - a spread too wide for analysis. Instead, the number
of months each LPA had been producing reports was calculated. This metric allowed LPA
citation analysis to be limited to those LPAs who had a full 5+ years of reports in the file.
Nine LPAs met that criterion.
Table 25 describes the number of citations by LPA, by type (A, B, or Unknown).
Citation patterns can clearly been seen by the Citations-Per-Month metric; this metric was
derived by taking the total citations issued by the LPA divided by the months of the LPA’s
tenure in the office.
Table 25 shows totals of citations, by type, issued by the LPA on either a LIC 809
or LIC 9099 form. Review of the data shows LPA 28 is an outlier in all metrics collected.
In Citations-Per-Month, LPA 28 out-cited the closest (in terms of total months of writing
reports) colleague (LPA 16) by a factor of 4 (2.5/mo. to 11/mo.), issued nearly 7 times the
number of Type A citations, and nearly 3 times the number of Type B citations, as LPA
16. Despite LPA 28’s proclivity to issue citations, the individual is also responsible for the
highest frequency of Failures to Cite. The remaining eight LPAs combined barely out-cite
LPA 28 (13.2 to 11); the mean Citations-Per-Month for these eight is 1.65 citations-permonth. These findings are difficult to interpret without knowing individual workloads of
each LPA, or their education and prior experience before coming to CCL. It would be useful
to have this information to understand why, given the same time and resources as 8 others,
one LPA demonstrates such stark differences in citing deficiencies.
These findings of variations in citation patterns are in consonance with earlier findings
where regional citation patterns (Corrigan, 2003) among SNF evaluators were identified, and
68
consistent with trends noted by Flores, Newcomer, et al. (2008) where regional office citation
patterns in California were also identified.
69
Chapter 5
DISCUSSION
This study addressed findings in four key areas where important findings emerged:
Facility Characteristics, Staffing, Finances, and Enforcement. A fifth, and untended finding
of the study was the pervasive shambles of the CCLD files. It is acknowledged that the
overarching study design was derived from the two Flores papers (Flores, Bostrom, et al.,
2008; Flores, Newcomer, et al., 2008), but many of the findings presented herein were not
in those earlier papers. Also, in some cases, similar topics were addressed by this paper,
but the data was not analyzed or reported in the same way as in the earlier papers, therefore
apples-and-apples comparisons frequently cannot be made.
Facility Characteristics
Facility characteristics included the finding that 96% of the sample RCFEs are forprofit organizations, which mirrored national growth trends, particularly among the 1-6 bed
facility demographic. Also significant, 80% of all facilities are Strata 1 (1-6 bed facilities)
yet account for only 18% of all regional beds, while 7% of RCFEs (Strata 5 or 100+ beds)
account for the preponderance of the regional bed capacity (68%). The demographic findings
of this paper closely matched those of Flores, Bostrom, et al. (2008).
Two significant irregularities were found: 12% of facilities licensed by CCLD are
disqualified to do business in the state of California, as evidenced by documentation available
from California’s Secretary of State’s office. Secondly, 60% of the RCFE Licenses in the
files were failed to correctly reflect the services the facility was authorized to provide.
Neither of the Flores, Bostom, et al. (2008) or Flores, Newcomer, et al. (2008) studies
addressed this facility characteristic, and no literature could be found regarding California
RCFEs to place this finding in context.
70
Within the Staff findings, fewer than 12% of all RCFEs report hiring any skilled
medical professions, fewer than 10% of RCFEs report hiring any specialized housekeeping
or culinary staff, and 47% of all facilities hire only between 2 and 4 caregiver staff. 50%
of all facilities report having a total payroll of between 1 and 5 employees. 73% of all files
reviewed do not contain a specific caregiver job requirement for English proficiency. The
irregularity of these findings is not any discrete finding, but rather the collective implication
of short-staffing and inadequate staffing necessary to care for the resident acuity levels
allowed by Title 22.
The Flores, Newcomer, et al. (2008) study also found incomplete LIC 500s in the
file, but the remainder of this study’s findings were not reported by Flores, Newcomer, et
al. (2008). Northern California staffing patterns by job category were not reported in either
Flores study.
Finances
Findings related to finances were instructive. Average room rates are to between
$2,020 and $4,233, depending facility size; the average monthly food costs as a percentage of
facility revenues ranged between 2.3% and 7.8%. These percentages equate to average per/
day-per/resident food allowances of between $3.82 and $6.62, with the range being between
.81/day and $26.13/day – depending on the Strata of the facility. Facilities reported average
monthly profits from between 13.7% to 31% with the range being between -12%, to +72%.
Again, no discrete finding is “irregular;” the irregularities are rather a constellation of issues
implied by the apparent impossibility of feeding a frail elder 3 meals, 2 snacks, and adequate
hydration on 81 cents, or $3.82 a day. The per/day-per/resident daily food allowance also
becomes problematic against average estimated profits of between nearly 14% and 72%; the
profit margins themselves are not irregular, they only become problematic juxtaposed against
the low food budgets. Neither Flores study addressed analysis of the LIC 401, or any finding
related to those presented in this paper regarding daily food allowance budgets, or profit
margins (Flores, Bostrom, et al., 2008; Flores, Newcomer, et al., 2008).
71
Enforcement
Encorcement findings revealed irregularities in many areas: Citations by Type, LPA
citation patterns, civil penalty collections, failing to cite stated deficiencies, and the revelation
of the Top-10 most cited -regulations.
This study found that 64% of all citations issued were Type A whereas, the Flores,
Newcomer, et al. (2008) study found 52.6% Type A, making the Northern California data
more evenly split between Type A and B citations, than the San Diego-Imperial county
sample.
Analysis of LPA citations patterns are apparent, where one LPA, alone, was found
to have written 41% of all citations issued from this in this regional office. Only 25% of all
Civil Penalty Assessments or Invoices found in the file were shown to have been paid; as a
percentage of all citations written (3,313) 248 deficiencies (7%) were not cited – these were
dubbed Failures to Cite. The Flores, Newcomer, et al. (2008) paper reported regional citation
patterns, but LPA patterns were not reported. The conclusion is that there is widespread
citation variation – from the LPA to the region – within California; this finding alone should
compel regulators to look at the inequities introduced in the citation process, particularly
since deficiencies cited are frequently used as a proxy for quality of care.
In terms of deficiencies by regulation, this paper presented its Top 10 most-cited
regulations. Accounting for nearly 17% of all citations was Incidental Medical and Dental
Services – the regulation addressing medication errors, inadequate medical care, and
neglect. The percentage is not, of itself irregular, yet taken in context of Title 22, which
allows retention of clients with many chronic and bedridden health conditions, and with the
staff finding that fewer than 12% of facilities employ skilled-medical staff, one cannot be
surprised that 17% of all citations, in fact, represent discrete, and perhaps, life-threatening
risks to the dependent and frail elder.
Substantially more citations for Incidental Medical and Dental Services were reported
by Flores, Newcomer, et al. (2008) than by this study sample: they reported 33.5% of all
72
citations were related to medical care requirements. This study is however congruent with
the Northern California study in that the most frequently cited regulation in both studies was
CCR Title 22 §87575 (2010), further suggesting the “irregularity” of this finding is in the
contraction of Title 22 allowing chronic health conditions, while not requiring skilled medical
staff to be employed by the facility.
File Condition
Findings related to file condition were unintended and unforeseen. While data in each
segment (Facility Characteristics, Staff, Finances, and Enforcement) were presented which
quantifies certain types of data either being missing, or incomplete, those data do not tell
the whole story: substantially all files reviewed were in some way, inadequate, incomplete,
evidenced misfiled papers belonging in other RCFE files, contradictory, referred to missing
documents, and some multi-page documents were only partially in evidence. The public
files are wholly inadequate for the consumer of long-term care to be able to adequately
assess suitability for the placement of their family member; the files’ inadequacy drives the
consumer of long-term care to unobjective and self-serving provider-information.
The Northern California study (Flores, Newcomer, et al., 2008) mentioned, in more
restrained terms, the incompleteness of the public record.
Implications of the Data
This study found pervasive issues with data quality, and with the quality of oversight
exercised by CCL. With data that was collected, the overall evaluation is of an incompetent,
ineffective and system of older adult care under some RCFEs and their oversight agency
CCL. The overall impression is that this lack of administrative integrity is not an issue
of resources—because there are instances where individuals work more efficiently than
others—the issue is one of incompetence and mis-management.
Although Title 22 is a broad and ambiguous set of regulations, there are nevertheless
specific requirements that some facilities do comply with. There are also state laws that bar
73
some facilities from operating, and yet they are still licensed by the CCL. The finding that
12% of the Licensees are disqualified to do business in the state, and yet are operating going
concerns, is illegal, and CCL is liable for licensing them.
The consumer must question the level of due diligence demonstrated by CCL in
continuing to renew the licenses of Licensees no longer qualified to do business in California.
The final implication of this finding is the possible undermining of CCLs’ regulatory ability.
If Licensees continue to do business when they are disqualified to do business in the state,
then all other regulatory actions taken by CCL may be called into question as well.
Although this study has highlighted a situation that questions the effectiveness of
San Diego Regional Office’s oversight, the situation is getting worse. The 400% increase
among small facilities (Strata 1) since 2000, coupled with the finding that 80% of the RCFEs
in San Diego and Imperial counties accounts for only 18% of the bed supply suggests CCL
is devoting significant resources to licensing and regulating these new arrivals. Literature
has noted that such growth among assisted living options has been spurred by increases
in the aging population, although the regulations themselves incubate the growth. These
regulations include the low application fees ($825, with annual renewals under $500)
(CCLD, 2009); 3 months start-up assets (including credit card balances) are easily posted,
and short of the required 40 hours Administrator certification training, it requires only a
high school education, and no related experience to be an owner or administrator. Added
incentives are the financial leveraging opportunities: the Licensee can own the property,
pay himself non-market-rate rent, and aided by subsidized HUD mortgages (Section 232
programs) (GAO, 2006), transform a residential care facility into a real estate venture, as the
RCFE becomes the vehicle for acquiring investment property.
One of the offshoots of this growth is that the number and type of RCFEs are
changing rapidly, becoming smaller, more privately owned, attracting patients that are older,
and more incapacitated than before. The implications of this growth suggest CCL’s resources
may be experiencing pre-licensing and surveillance workload increases. In addition, when
74
90% of the RCFEs in San Diego & Imperial counties are for-profit facilities, the focus is
profit. Consumers of long-term care must recognize that for-profit facility owners will
make care decisions based on the bottom line, and in doing so, resident outcomes may take
secondary priority.
That 60% of facility Licenses in the public files are incorrect, missing from the file,
or so unclear or ambiguous as to be incorrect, again reinforces the finding that this an issue
of administrative ineffectiveness, rather than lack of LPAs. Documents represent “fact,” and
RCFE Licenses should represent “proof” of what services the Licensee is authorized by the
state to provide. The state, as regulator, has a duty to be competent, and the public has the
right to rely on the correctness of a state-issued license.
The key to quality of life and care is adequate staff (Schaffner, 2008; Schnelle et
al., 2004), yet California’s RCFEs are understaffed by design; the regulations require only
the bare minimum (“sufficient in number”), a number that is discretionary to the Licensee.
Consistent with Title 22’s one-level approach to regulation, staffing requirements for a
15-bed facility and a 250-bed facility are essentially the same. This is an issue with the
ambivalence of the State law. However the repercussions from inadequate stipulations
are that as clients require additional services--hospice, dementia care, bedridden, oxygen
administration--the staffing requirement remains the same. There are no stair-stepped staff
requirements. Twenty-five years ago, Harrington noted that as the level of needs increases
for nursing home residents, the care provided, by necessity, becomes more labor intense and
more complex; consequently, caregivers have more to do (1991). Recent literature suggests
that the differences between resident acuity levels in assisting living are approaching, and in
some cases, are indistinguishable from nursing home residents (Hawes et al., 2003).
Title 22 does not mandate that staffing must change as both case mix and resident
acuity levels change – instead it continues to rely on the Licensee’s discretion. RCFEs are
non-medical housing arrangements that do not require skilled medical professionals to work
in the facility, but the fact that only 20% of the facilities employ Registered Nurses, CNAs,
75
LVNs, or LPNs suggests recognition that the acuity levels housed in residential care require
additional care and greater numbers of skilled professionals, over and above the care one
would expect to find in a non-medical housing alternative. Not having skilled medical
professionals in a facility caring for residents with chronic health conditions such as IPPB
machines, oxygen administration and bedridden residents may put residents at greater risk of
not being observed for changes in their health status (Hawes et al., 2003).
In addition, other types of staff are missing in RCFEs: Title 22 does not address
requirements for housekeeping staff; instead §87565 states “additional staff shall be
employed as necessary to perform... house cleaning, [and] laundering...”, again a
“discretionary requirement.” The findings of this study showing that nearly 90% of all
facilities do not employ kitchen, culinary, or housekeeping staff, lends weight to the
observations of others (Carlson, 2005; Hawes et al., 2000) that caregivers wear many hats:
cooking, cleaning, laundry, and all other “household” chores.
The conclusion is apparent; facilities seem understaffed by design. When the largest
percentage of facilities has a total staff of between 1 and 5, coupled with the finding that
caregivers care for residents and do all other housekeeping chores, the implication is twofold: resident care must necessarily suffer, and caregiver burnout may contribute to the
number onecitation §87575-Incidental Medical and Dental Care, issued for medication error
including incorrect or missed doses, incorrect or neglectful medical care.
Reviewing the job qualification and descriptions is part of how RCFEs are meeting
the “communication” requirement of Title 22. Given that 72% of the facility files do not
expressly state that able communication in English is a job requirement, the finding appears
to imply that it is handled implicitly. In view of the Assisted Living Federation of America
reporting that for 70% of caregivers English is not their first language, it is more than likely
that a large proportion of the caregivers have variable English skills (Nickerson, n.d.). There
is no way to ascertain how many fluent English speakers work in California RCFEs, but
the consequences are clear; when “staff members do not speak the language of residents,
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barriers to communication become barriers to providing optimal care” (Namazi & Chafetz,
2000).
It is not just English proficiency but also the level and type of staff that are employed
in RCFEs that are of concern. The fact that 176 facilities have between 1 and 5 staff for 24/7
care of 6 residents, suggests that CCL does not vet the data submitted to it. It is unlikely that
five individuals can run a facility 24 hours a day, 7 days a week, for 365 consecutive days,
performing the tasks of providing care and supervision to 6 residents with high acuity needs,
along with all domestic chores.
Staff levels and qualifications are the backbone of resident care, and are central to the
quality-of-care received by residents, yet information about staffing characteristics, training,
turnover, wages, competency or correlation to quality of care in the California RCFE are
little understood as reliable data is not available for analysis because of the absence of
documentation in approximately 75% of files.
The findings of per-day rental rates, derived from annual monthly revenues, suggest
that residents who rely on SSI stipends to cover their assisted living needs may have
difficulty obtaining suitable housing at affordable rates, since the lowest average monthly rate
(Strata 2) is nearly three times the SSI rate.
The monthly revenue/per-day rental rate is a key benchmark for comparing the
relative value of cost elements, as they contribute to the perceived quality of care the resident
is purchasing, versus what he is receiving. Knowing that the Strata 1 per-resident-day food
allowance is $6.64 (7.8%), while profit is $20.11/day may provide ammunition for family
members to effectively advocate for the facility to increase the per-day-per-resident food
allowance to provide for improved meals, or to spend an extra $50 per month for a special
resident activity.
The analysis looking at cost of food exemplifies the business-driven model of
RCFEs, A Place for Mom (2010) provides a matrix of costs the average elder, living alone,
would incur versus the average cost of living in assisted living. Their analysis shows that
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the average solo-living elder, spends an average of $16.46 per day on food. Yet data in this
study shows that RCFE’s per-day/per-person expenditure on food equates to what A Place for
Mom reports per meal. The suggestion here is that while an elder living in his own home,
would spend $16 per day on food, that same elder, living in an all-inclusive RCFE, would
“save” $10 per day in food costs, when in fact he would be receiving 3 meals, snacks and
adequate hydration on a daily allowance of 1/3 [or less] that amount. Intuitively, it is difficult
to argue that a person eating on nominally $6 per day receives either the quality or quantity
of food of a person eating on $16 per day. This disparity places a fine point on the need for
complete data in the public record, and external evaluation of the quality of care.
The findings that in Strata 2 facilities (7 -15 beds), the daily food allowance/perresident is less than the level set by USDA’s Low-Cost Plan for 71 year old individuals and
older, coupled with the literature stating that residents of some nursing homes and assisted
living facilities are malnourished, suggests that residents are, in some cases, receiving lessthan-bargained-for value for their monthly room rental rate. Another implication of these
findings is that it appears CCL personnel do not perform rudimentary checks on the estimated
monthly food allowances: it is startling that 3 meals, 2 snacks, and adequate fluids could
be provided for the reported costs of $.82, $1.52, $2.87 or $3.13 per day as reported on LIC
401s in the files.
One difference between the USDA Daily Food Plan Averages and those of the RCFE
is that the individuals who crafted the USDA numbers are likely dietary and nutritional
experts with strategic shopping habits, while RCFE owners are not required to have
experience of any kind prior to opening a facility, therefore this researcher is skeptical that
RCFE owners could achieve as much nutritional “bang-for-the-buck” on the daily food
plan averages as the USDA dieticians could. Therefore any average daily rates less than the
USDA food plans become problematic for delivering quality food with maximum nutrition.
Findings as to LPA citations patterns are consistent with the variability noted in the
earlier-reviewed literature. Without additional knowledge about an LPA’s education, training,
78
prior experience, and caseload mix, it is impossible to draw any conclusions regarding the
clearly evidence citation patterns. But a fair question is why such wide disparity in citations
and visits for similarly situated LPAs? Do some LPAs work more, or smarter than others?
As an example, LPA 9, has the lowest number of visits, citations, and average hours per visit,
for a similar number of hours in the field as LPA 3. What accounts for these disparities:
Differences in productivity? Failures to recognize deficiencies? Differences in how one LPA
sees her role as enforcer?
The descriptive findings about citation types, or quantity of inspection and citation
data, are not nearly as important as the finding of the patterns of Failure to Cite, and Missing
Documents. The implication of the Failures to Cite is that LPAs are exercising discretion
over what their mandate is regarding the regulations: If there is a deficiency within a
regulation, the Licensee is supposed to receive a citation. Title 22 does not provide for
warnings, or grace periods. The law might be vague, but where it stipulates procedure, in
some cases LPAs are ignoring it.
Missing documents, missing pages, and incomplete data has been a recurring theme
of this investigation. Failures of the public record to be complete, correct, and accurate
engender mistrust among the public regarding the reliability of any information in the file.
That the files are consistently not reliable undermines the credibility of the public record, and
calls into question the agency’s ability to regulate for the benefit of California’s residential
care elder population. Many more missing documents exist–more than were exposed in
this study. Those identified in this study were exposed through careful reading of nearly
all other documents in the file. The only clue to recognizing there was a document missing
was when another document referred to it. Anecdotally, one CCL liaison indicated that this
CCLD office was “years behind...” in their filing, but maintaining public files is a primary
and necessary duty of this certification and oversight entity; one can only conclude that CCL
is incompetently performing their assigned task (C. Murphy, personal communication, 2009).
Because some LPAs seem to work more efficiently than others, that some files are more
79
complete than others, and that there is a pattern for this (small facilities receiving higher
vigilance), it is likely that this is not a resource issue, but a management problem, that limits
the ability of the consumer to see a complete picture of the RCFE that should exist in the
public file.
The findings demonstrating patterns in the way small bed facilities are cited over
large bed facilities raises the question why are large facilities receiving fewer citations on
a per-bed basis, than smaller facilities. This suggests that CCL may have a bias against
small providers, over larger ones. The Top-Ten Citations describe an interplay between
resident care, and the findings throughout this study: RCFEs are non-medical facilities,
but the top cited regulation deals exclusively with medication and medical care. Dementia
care is the second most frequently cited regulation, yet this study found that Dementia care
is not regularly or consistently listed on the License as a service the facility can provide.
The discussion on finance directly ties to and is suggestive of the 7th most frequently
cited regulation – issues related to food safety, inadequate food stores as required by the
regulations, and insufficient food portions for residents. The amount a Licensee budgets for
per-resident-per-month food allowance, is associated with the frequency this regulation is
cited.
The implications of the finding suggests that one of the most important enforcement
tools at the disposal of CCL is being used incorrectly, with an apparent failure to collect
75% of assessed Civil Penalties suggests that CCL has inadequate staff, systems, or internal
protocols to assure that Civil Penalties are the deterrent to poor performance, as they were
intended.
When a consumer goes to the public file, if the RCFE of the file he is reviewing had
a noncompliance conference, the consumer is entitled to see the summary. A noncompliance
conference is another level of enforcement intended to induce the Licensee to come into and
stay in compliance. It occurs usually when egregious events have taken place at the facility.
In the absence of the public record being complete, the consumer will have no knowledge to
be on his guard.
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Also of concern regarding the findings of noncompliance conferences is that the
twenty-two facilities that had these mandatory meetings had very high numbers of both
accumulated citations and visit frequency. The findings suggest that perhaps CCL provides
many opportunities for the Licensee to come into compliance, and that in so doing, the
resident’s health and safety are at risk for longer than necessary if CCL would have acted
sooner.
The striking patterns of citation, as to type and frequency, by LPA call into question
whether the one outlier LPA is particularly skilled over and above the others, or whether the
others are simply not as aggressive enforcement officers of Title 22 as they should be.
In
these times of furloughs and statewide budget cuts, CCL has started to cut services on the
grounds there are insufficient personnel to do the work. Comparing the productivity of
one LPA (as shown by the findings) with 8 other experienced LPAs, suggest that perhaps
there aren’t insufficient personnel to do the work, but perhaps only insufficient numbers of
competent personnel to do the job.
The findings from this study point to an ineffective and capricious system of
management of CCL, and that RCFEs are run on a business model that places the care and
safety of its clients secondary to the profit margin without any real oversight for the health
and safety of its clients.
Recommendations for Future Study
Three areas recommended for future study are License Reliability, Financial Data,
and Civil Penalty Issues.
License Reliability
The finding that 60% of all licenses in the sample are incorrect, unclear, ambiguous,
and not supported by documentation in the file suggests a major gap in the consumer’s ability
to rely on the RCFE License as a correct statement of what services the state has authorized
the facility to provide. Future work should be done to determine if similar findings result
81
from studies performed in other regional offices. It will be important to research whether
the findings of this study are peculiar to this regional office, or if incorrect and unreliable
Licenses are a systemic hallmark of the licensing agency. Neither the Flores, Bostrom, et al.
(2008) nor the Flores, Newcomer, et al. (2008) papers reported on whether they were able to
validate the correctness of the license based documentation in the file, or whether they looked
at that variable. No prior literature could be found which addressed the licensing anomaly
found in this study.
Financial Data
Understanding the business operations of the RCFE will inform how regulations
should be written to assure the priority of any Licensee is the resident first, and profits
second. Using professional cost accountants and those knowledgeable in how RCFEs
operated must work in tandem to perform detailed analysis of a much larger sample of LIC
401s advance this knowledge domain. Future research should also include surveys of the
LPAs who review the LIC 401s to gauge their understanding of the content presented on the
form.
Civil Penalties
Assuming Civil Penalties are intended to encourage compliance of noncompliant
Licensee, it would seem necessary that to have a deterring effect, the penalties would have
to be collected. That only 25% of the civil penalties assessed were shown to have been
collected, suggests Licensees are not paying the fines. Further, it would suggest that CCL
itself doesn’t have an adequate tracking system for follow up or collection. Understanding
the errors in CP assessments, the omissions in collection, and the methods used by CCL
to track CP payment would inform recommendations for regulatory reform (i.e., an RCFE
cannot renew it’s license until all outstanding Civil Penalties are paid.)
There are many opportunities for rich exploration of the public records of San Diego
and Imperial county RCFEs, beyond those presented in this paper: understanding how an
82
LPA decides the outcome of a complaint or unusual incident report would help the consumer
of long-term care assess how seriously and in-depth the state’s investigative procedures are to
assure resident safety; another important avenue of inquiry would be to conduct a survey of
RCFEs to validate the veracity of the LIC 500 Personnel report. The consumer of long-term
care would like assurances that the quality, quantity, and qualifications of the staff employed
by any given RCFE are satisfactory to, and suitable for the level of caregiving required by
the resident.
With the expected growth in the assisted living industry over the next thirty years,
investigations that describe and reveal supporting housing characteristics will assure
accountability for the care of the Boomer generation.
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Chapter 6
LIMITATIONS
Limitations of this study, and recommendations for future research are the subject
of this chapter. There are many more limitations to this study than mentioned below; those
mentioned were thought to be the most significant in terms of final study outcome. So too,
recommendations for future research are myriad, however those discussed are those believed
to yield the greatest opportunity for exacting accountability from the regulatory agency –
CCL.
Missing Documentation
A significant limitation of this study is the extent of the flawed source documentation
available in the public file. Files are frequently incomplete as shown by widespread missing
documents, documents are fragmented (only page 3 of a 10 page document will be in the
file), and for incomplete or inaccurate data submitted by the Licensee, it is not apparent that
Licensees are ever asked to provide corrections. Therefore, findings of this study cannot
be generalized to either Community Care Licensing’s patterns of statewide licensure and
enforcement, nor can they characterize RCFE attributes through the state. The extent of
incomplete data may have caused patterns to be over- or understated.
Limited Data: One Region
A second limitation is that data was obtained only from one regional district office
responsible for only a portion of the RCFE bed supply in California. Because files were
reviewed from one venue, no comparisons can be made with other regional office patterns,
nor can findings be generalized, or applied, to any other CCL Regional office. This
limitation may be offset, in part, by the robustness of the sample (50% sample of all RCFEs
in San Diego and Imperial counties, of January 2009; the robustness of the sample may in
84
small part lend more credibility to the findings than if the data were just collected from one
venue, using only a 10% or 20% representative sample.
Limited Data: Facilities not Residents
A significant limitation of this investigation is that the data does not reveal many
characteristics surrounding the resident and resident health outcomes that would be useful
in characterizing the RCFE’s ability to deliver quality-of-care, in much the same way as the
Minimum Data Set provides similar information for SNF residents. Therefore, the data are
limited to facility and regulatory characteristics.
Qualitative Data
Data collected for this study consisted of both quantitative and qualitative data; only
quantitative data was only used for this study. Perhaps larger use of the collected qualitative
data, in concert with the quantitative data would have added flesh and nuance to the
descriptive findings presented.
Financial Data
Financial data (LIC 401) was problematic; in retrospect, this researcher should have
consulted with others to derive a consistent methodology for “backing into” per- resident
costs, especially in cases where inadequate or incomplete data existed, and particularly for
those facilities that understated their capacities. As a result, the data presented cannot be
generalized, may be useful for indicating trends or approximations of on-the-ground costs,
but provide only gross estimates of economic factors. Formal economic analysis needs to
be undertaken to establish meaningful metrics for RCFE operations and for determining the
effect of fiscal practices on quality of care delivered by RCFEs.
Data Collection Techniques
All of the data were collected, coded, and analyzed by one researcher, and therefore,
the potential for error may be greater than if multiple investigators were involved in these
aspects of the study.
85
Chapter 7
CONCLUSIONS
California’s regulation of residential care facilities for the elderly is hampered by outmoded regulations, regulatory failures including inconsistent enforcement, and widespread
missing documentation from the public record. Three overarching conclusions based on the
findings presented by this study, are offered:
Non-Medical Model is a Fiction
The non-medical alternative housing model promulgated by Title 22 is a fiction. This
conclusion results from the accumulated weight of factors presented in study:
• Research noted in this paper that residents of assisted living facilities require services
and assistance “comparable to those provided in nursing homes” (Hawes et al., 2003).
• Findings of this study showed that RCFEs (albeit in small percentages), even without
a regulatory requirement to do so, are hiring clinical staff; presumably these RCFE
Licensees see skilled medical professionals as necessary to adequately care for
residents with chronic medical conditions they are allowed, by Title 22, to retain.
• Title 22 regulations permit Licensees to accept and retain residents with chronic and
serious medical issues, (oxygen administration, bedridden, diabetes, IPPB machines,
indwelling catheters, etc), but paradoxically requires no skilled medical professionals
to be employed by the facility to care for these conditions, and employ few care staffto-resident ratios to ensure delivery of quality care.
• This study’s findings that CCLD has provided (a) hospice waivers to about 65% of
the sampled RCFEs, (b) bedridden approvals (allowing Licensees to retain individuals
who are perennially confined to bed, unable to turn or transfer without assistance) to
about 13% of RCFEs, and (c) allows for care of progressively demented residents in
an unquantified number of RCFEs.
• Findings of this, and the Flores, Bostrom, et al. (2008) and Flores, Newcomer, et al.
(2008)studies, show that the most frequently cited regulation evidencing Licensee’s
deficiencies is Incidental Medical and Dental Services – the regulation covering
medication errors, and inappropriate medical care.
• And anecdotally, this researcher was told, anonymously, by three individuals
employed by CCLD that RCFEs are becoming “mini-nursing homes.”
86
This set of factors demonstrates that RCFEs are not benign alternative housing. Elder
Law Attorney, Eric Carlson sums up the California’s assisted living dichotomy this way:
“Today, assisted living facilities expect to have it both ways. They want to be able to admit
and retain residents with serious health care needs, but they reject the application of health
care standards,” (Carlson, 2010).
Regulatory Gaps are Myriad
Regulatory gaps or incompetence appear to be systemic: from enforcement failures
of under citing, inconsistent interpretations of the regulations by individual LPAs, the
unexplained discretion exercised by an LPA when not citing for a deficiency, failure to
correctly assess, or to collect assessed Civil Penalties, the long fuse afforded noncompliant
facilities before CCL elects to conduct mandatory Noncompliance Conferences – all bespeak
regulatory or agency management failures.
Missing Data from the Public Record
The pattern of missing data throughout the public file recalls the words of Tabachnick
and Fidel, “The pattern of missing data is more important than the amount missing” (2007).
The widespread pattern, and the quantity of missing data demonstrate a failure of
the agency to respect the public record. Missing documentation contributes to information
asymmetry (Teitelbaum & Wilensky, 2007). Knowledge and information not reported, or
not available in the public record, prevents consumers from knowing what the regulators
and individual RCFE owners know about resident care, and regulatory compliance. CCL’s
incomplete public record creates a vacuum being filled with provider-centric information:
nowhere is this more apparent than the recent addition to the CCL website, where providers
can post information about their individual facility (http://www.ccld.ca.gov/myccl). CCL
should instead be posting citation and inspection information about providers rather than
letting providers advertise on the state’s website.
87
That 60% of the RCFE Licenses available to a consumer performing due-diligence
prior to placing a family or loved one, are wrong, incomplete, or is unconscionable. That
50% of noncompliance summaries are not in the public record for all to see is reprehensible.
The public, and the consumer of long-term care has a right to know what goes on
inside the RCFE. The findings of this study suggest that CCL has abdicated its duty to serve
the resident, the consumer of long-term care, and the public, in favor of serving the Licensee.
88
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94
appendix a
SAMPLE LIC 809
95
Figure 7. LIC 809.
96
APPENDIX B
CPRA REQUEST LETTER
97
Figure 8. CPRA request letter.
98
Figure 9. Enclosure 1 to C.M. Murphy.
99
appendix c
rcfe file organization
100
Table 26. CCLD File Organization
Left Side (In Customary Order of Appearance)
Facility Profile: A CCLD generated document containing summary data about Licensee, Facility and Last Visit
to Facility
Facility License: Documents bed capacity, resident qualifications and services CCLD has authorized licensee to
provide to consumer of long-term care
Application – LIC200: The LIC 200 is the original application for licensure which is submitted to CCLD, along
with other documents required by the licensure process.
TAB – Organization and Administration:
• Designation of authority (person who will act as representative of licensee for matters related to the licensure
and enforcement
• California Secretary of State Statement of Information if Licensee is a legal entity rather than a sole
proprietor
• Articles of Incorporation (if License is a legal entity.
TAB – Financial Information:
• LIC 401 Estimate of Monthly Expenses and Revenues. (This document is only submitted during the license
application and updates are generally not available.)
• Receipts for payment of Civil Penalties or Renewal Fees.
TAB – Personnel/Staffing
• LIC500 – Staff Inventory documenting name, staff position and hours to be worked in the facility.
• Job Descriptions
TAB – Physical Plant
• Plant Sketch
• Fire Marshal Clearance
• Emergency Plan of Operation
TAB – Programs and Plans of Operation
• Admission Agreement
• Dementia Plan of Operation
• General Plan of Operation
• Hospice Plan of Operation
• Bedridden Plan of Operation
• AB 2609 Compliance Plan
• Not all of these Plans are applicable to every RCFE; they are highly dependent on the types of services
Licensee intends to provide.
Right Side (In Customary Order of Appearance)
Contact Sheet: Typically documents telephone conversations with Licensee, agent, or state or local agency
Evaluations & Investigations
• LIC 809 – Prelicensure visits, Evaluations, Case Management, Annual Survey, Required 5 year Survey
Report
• LIC 9099 – Complaint or Investigation report
• Civil Penalty Assessments
• Civil Penalty Invoices
• Non-Compliance Conference Summaries
• LIC 9098 – Self Certification of Deficiency Correction by Licensee
• Miscellaneous Documents (photos of corrections, receipts of payment for required services)
Correspondence
• Letters to and from CCL
• Letters to and from Licensee
• Documents from agencies, subpoenas, miscellaneous documents (photos of corrections, receipts of payment
for required services.)
101
APPENDIX D
Variables collected, with source
102
Table 27. File Protocol Sheet (FPS) Fields
Top-Level Field
Master File Number
Date of Review
File Observations
Facility License
TAB
TAB
TAB
TAB
TAB
Organization and
Administration
Finance
Personnel
Physical Plant Tab
Programs
Sub-Tier Fields
Subjective comments and observations of the researcher
on file content, completeness, irregularities,
inconsistencies.
Does the License Match other documents in the file. Yes
if the license reflected authorizing documents in file. No
if the license granted more or fewer approvals than
documented in the file. Unk if the file did not contain a
license.
Most Current License (LIC203A) in file
License Reads
Date of Latest LIC 200 Application
Reason for application: new, increase in capacity, change
in resident status (ambulatory, non-ambulatory, bedridden,
hospice), change of ownership, change of location
Former facility name if any
Former facility License number, if applicable
Control of Property (Evidence of) : Lease agreement (LA),
rental agreement (RA), deed (Deed), Not-in-file (NIF)
Was a LIC401 in file? If Yes – a date was entered, if one
was not in the file (NIF), coded as NIF.
Was the LIC401 was properly completed? If LIC401 was
incomplete or not in file, the code was No
Was an Affirmative Surety Bond in the file?
Date of Last Personnel Report LIC 500 in file.
Was evidence of AB2609 (H&SC 1569.69) Staff Training
on Medication in file?
Date of Most Recent Fire Marshal Clearance (FMC) in
file.
If FMC approved facility for bedridden residents was there
a CCLD statement requiring additional staff?
Emergency Disaster Plan (LIC610E). If file contained a
LIC 610E, the date was recorded. If not found in file,
coded NIF
Were the following plan types found in the file?
Hospice Plan of Operation
Dementia Plan of Operation
Elder Abuse or Mandated Reporter Policy
Bedridden Plan of Operation
Admissions Agreement
If Yes, the following data was collected:
Requirement for Pre-Admission Fee
Personal Rights (Title 22 §87572)
Eviction Clause
Data Recorded
Researcher assigned number
Date
Comments
Yes/No/Unk
Date appearing on LIC203A
Summary of capacity, and
approvals granted by CCLD
to the facility taken directly
from license, in many cases
verbatim
Date
Reason
Name
Old License #
LA/RA/Deed/NIF
Date/NIF
Yes/No
Yes/No
Date
If yes, the date. If not, NO
Date
N/A if FMC didn’t address
bedridden.
2 if 2 staff were stipulated by
CCLD
Zero if no additional staff
were stipulated.
Date/NIF
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
103
Table 28. Facility List Fields
Top-Level Field
Master File Number
Date of Review
Facility Information
Licensee Information
Financial Information
Sub-Tier Fields
Facility Name
Facility Street Address
Facility City
Facility Zip Code
Facility Phone Number
Facility License Number
Initial Operational Date of Facility
Administrator’s Name – most current in file
Licensee (Owner) Name or Legal Entity
If Corporation or LLC
State of Incorp
Agent for Service
Corporation or LLC number
Organizational Type: Individual (Sole Proprietorship),
Partnership, NFP Corporation, For-Profit Corporation,
Courts, Other Public Agency, Limited Liability Entity,
Limited Partnership
Licensee Address
Licensee City
Licensee Zip
Licensee Phone Number
Property Owner and Address
Licensure Status: A = active. C = Closed
Beds
Stratified Category ( 1-6 = 1) (7-15 = 2) (16 – 49 = 3) (50
– 99 = 4) (100+ = 5)
# Non-Ambulatory (N/A) Residents Authorized
Documentation for N/A Authorization
# Approved Hospice Waivers
Documentation for Hospice Waivers
# Approved Bedridden Residents
Documentation for Bedridden Residents
Dementia Care or Dementia Waiver (not required since
2004)
Alarmed Exits (obtained from file either as affirmative
yes, affirmative no, or unable to tell = Unknown)
Self-Latching Or Delayed Egress Perimeter (obtained from
file either as affirmative yes, affirmative no, or unable to
tell = Unknown)
Date of Last Deferred Inspection
Reason for Deferred Inspection (SS = stated staff
shortage)
Date of Most Recent LIC 809 or 9099 in file.
Date Facility Profile states was most recent visit (LIC809
or 9099) to facility)
LIC 401 in file?
Date of LIC 401 if available
Line 3 – Average Monthly Room Rate
Line 6 – Monthly Revenues
Line 7 – Food Costs
Line 16 – Wages
Data Recorded
Linked Number
Linked Date
Name
Address
City
Zip
Phone Number
License Number
Date
Name
Name
State
Name of Agent
Number
Coded by Org type
Address
City
Zip
Phone Number
Name/Address/City/Zip
A/C
# from License
Applicable Code
Number
Yes/No
Number
Yes/No
Number
Yes/No
Yes/No
Yes/No/Unk
Yes/No/Unk
Date/0
SS/0
Date
Date
Yes or No
Date
Either from form or
calculated revenues/beds
Data from form
Data from form
Data from form
104
Table 29. Staff Sheet Fields
Top-Level Field
Master File Number
Date of Review
Dates of Personnel
Reports (LIC 500) in
file
Registered Nurses (RN)
Certified Nurses
Assistants (CNAs)
Culinary Staff
Housekeeping Staff
Licensed Vocational
Nurse (LVN) or
Licensed Practical
Nurse (LPN)
Administrator/s
Caregiver
Staff Total
Job Qualifications –
Caregiver Required to
speak English?
Comments
Sub-Tier Fields
LIC 500 Forms are required annually. Dates of each LIC
500 in the file, for the period 1/1/2000 through the date of
file review were recorded.
Count of RNs facility reports it has, or (in the case of new
facilities awaiting licensure) will have on staff
Count of CNAs facility reports it has, or (in the case of
new facilities awaiting licensure) will have on staff
Count of Culinary Staff facility reports it has, or (in the
case of new facilities awaiting licensure) will have on staff
Count of Housekeeping staff facility reports it has, or (in
the case of new facilities awaiting licensure) will have on
staff
Count of LVNs or LPNs facility reports it has, or (in the
case of new facilities awaiting licensure) will have on staff
Count of number of Administrators facility reports it has,
or (in the case of new facilities awaiting licensure) will
have on staff
Count of Caregivers facility reports it has, or (in the case
of new facilities awaiting licensure) will have on staff
Total number of staff positions reported by facility that it
has, or (in the case of new facilities awaiting licensure)
will have on staff
Review was made of the Job qualifications filed in the
Personnel Tab. Job qualifications for caregivers were
reviewed to determine whether there was a hiring
requirement that caregiver speak English. Coded as
Yes/No
In this field the researcher noted information which was
relevant but for which no data collection field had been
created (i.e. same individual listed as gardener and also as
caregiver), or subjective comments relevant to either job
qualifications or staff count.
Data Recorded
Researcher assigned number
Date
Dates (oldest to most current)
#
#
#
#
#
#
#
#
Yes/No
Comments
105
Table 30. Evaluation and Complaint Sheet Fields
Top-Level Field
Master File Number
Date of Review
Inspection Date
LPA
Complaint Number
Reason for Visit
Outcome
Approximate Hours in
Facility
Class of Citation
Title 22
Enforcement Action
Nature of Enforcement
Date Due
Date Cleared
How Corrective Action
was Cleared
What Was Correction
Action
Statement of Deficiency
Comments
Sub-Tier Fields
Reviewed noted the date of visit (as much as could be
discerned)
In this sample there were 38 individual LPAs, and several
additional codes to account for illegible signature, not
signed, or unknown. Each LPA was given a code, and all
inspections, citations, investigations performed by that
LPA was coded with the assigned LPA number
If LIC document noted a complaint number it was
captured
If LIC document noted the reason for visit, it was
captured: 5-year evaluation, random annual, Annual, Case
Management, Complaint Investigation, Post licensing, Prelicensing, etc.
Statement of finding taken, as much as possible in
verbatim form. If text was too long, data was summarized
LIC forms have two fields “Time visit began” and “Time
Complete.” If data was in these fields, the researcher
determined the approximate time spent in the visit, to the
nearest quarter hour.
The class of citation (if) noted by the LPA on the LIC 809,
or LIC9099 (or their respective continuation forms) was
entered. 5 = cited by no type stated
The regulation number (if) cited by the LPA for a given
deficiency was picked off the LIC809 or LIC9099 and
entered into this field
Enforcement Action was either Not Applicable (0), Yes
(1) Unknown (3) or Rescinded (17)
Nature of Enforcement captured the method used by the
LPA to enforce: Not Applicable (0), Civil Penalty (1),
Citation Issued (4), and No enforcement where one could
have occurred (5)
The date correction of deficiency was required, as (if)
stated by LPA
The date the deficiency or enforcement action was actually
cleared as (if) stated by LPA
This field captured, to the extent possible, how correction
was cleared – either by submittal of Self Certification
Form LIC 9098, by an LPA visit, photos, etc.
Field captured, to the extent possible, what the nature of
the correction was, for example: a promise it wouldn’t
happen again, evidence of a fix or repair (photo or receipts
of payment of service),
To the greatest extent possible, researcher recorded
directly from the LPA’s written deficiency on the LIC 809
or LIC9099. Recording was either verbatim, or when
narrative was too long, summarized the deficiency.
Subjective commentary or observation by researcher
related to either CCL/ LPA actions, omissions or other
Data Recorded
Researcher assigned number
Date
Date
LPA Code #
Complaint Number
Text, then coded. See
Appendix F for Code
Dictionary (I – Case Code)
Text, then coded. See
Appendix F for Code
Dictionary (L – Finding
Code)
Hour or hours fractions
A/B/5
Reg #
Ex: 87572
Ex: 87691(e)(2)
0/1/3/17
0, 1, 4, 5
Date
Date
Text, then coded. See
Appendix F for Code
Dictionary (AL - How
Corrective Action was
Cleared)
Text, then coded. See
Appendix F for Code
Dictionary (AK – What Was
Corrective Action)
Text
106
appendix e
sample LIC 401
107
Figure 10. LIC 401.
108
appendix f
code dictionary (for inspections sheet
in workbook)
109
Table 31. Code Dictionary (Used to Code Sheet 4, Inspections)
CELL NAME/Title
B
COMPLAINT
G
LPA
I
CASE CODE
J
VISIT TYPE
L
FINDING
CODE
CODES
0 = Not applicable
X = complaint # picked from LIC doc
9999999 = was a complaint but no complaint # could be found on LIC doc
7777777 = Incident
0 = No LPA, Unk, not signed, N/A, not
21 = Nowaskaski
legible
25 = Delgado
2 = Wallace
26 = Wallace
3 = Tyner
27 = Naegeli
4 = Golembesky
28 = Focosi McKelvy
5 =Williams
29 = Jackson
6 = Smith
30 = Valero
7 = Minkin
31 = Littlepage
8 =Greene
32 = Fullwood
9 = Swinea
33 = S. High
10 = Levin
34 - Gray
12 = Maherman
35 = Steve Hawks
13= Gomez
36 = Manos
14 = Whittaker
37 = Marshall
15 = Sanchez
38 = Y. Richards
16 = Aguilar
39 = McGuire
17 = Lopez
40 = Casillas
18 = Ramos
41 = Guttierrez
19 = Uribe
42 = Lucero
20 = Moreno
43 = Taylor
1 = Annual Inspection/ Random Annual Inspection
2 = Prelicensing
3 = Post License Visit
4 = Case Management/Collateral Eval
5 = 5 year Inspection
6 = Complaint/Incident Investigation
7 = Follow up for complaint, deficiency, incident or other
15 = Not known
16 = Verify Closure
17 = Management Action
18 = Non-Compliance Conference
0 = Unk
1 = Unannounced
2 = Announced
4 = Postponed
1 = Substantial Compliance or NO deficiencies cited
112 = Substantial Compliance with Deficiencies
116 = Substantial compliance with failures to cite
2 = Deficiencies cited
211 = Deficiencies cited but missing docs
213 = deficiencies cited and NCC meeting scheduled or indicated
216 = Deficiencies cited but failures to cite
3 = Ready for Licensure or Licensed that date for new or added services
316 = Licensed but failure to cite
4 = Delivery or Pickup of Documents or Reports
5 = No statement of findings outcome/ Unknown
6 = Pre-licensing deficiency prior to licensure
(table continues)
110
Table 31. (continued)
CELL NAME/Title
M
N
APPROX HRS
@ FAC
O
Q
TITLE 22
100 = 6
200 = 7
300 = 8
CLASS OF
CITATION
CODES
7 = Reserved
8 = Unfounded Complaint
816 = Unfounded with failure to cite
9 = Substantiated Complaint
91 = Substantiated Complaint without citations
9116 = Substantiated complaint with failures to cite
92 = Substantiated Compliant WITH Citation
10 = Inconclusive Complaint
11 = Missing document - Public Doc referenced but not found in file
12 = Corrections made (resulting from LPA comment on form)
13 = CCL request for conference, training attendance, or Non-compliance
conference.
14 = No residents
15 = Facility Closure
16 = Failure to Cite: Licensee was not cited for something he should have been –
i.e. 2nd violation in 12 month period. May or may not be listed on LIC 809.
17 = No corrections made by Licensee
18 = Management Action
19 = Denied Entry or Attempted Visit
20 = other
0 = Not stated on LIC 809
X = hours picked from LIC 809
0 = N/A
1 = Reserved.
2 = Type A
3 = Type B
4 = Not cited but mentioned on LIC 809, may be accompanied by corrective action.
5 = Cited but no class (A/B) know or stated, like when you have to back into a
citation based on the CP document in file, or another LIC doc fills in missing info.
0 = N/A
1 = where facility received a substantial compliance
# = the specific regulation cited as having been violated
87575(c)(h), +
Medication: inappropriate, incorrect, missed, expired,
110
incorrect storage, not logged
87575(f)(4)
First Aid Training: no training, expired certification,
111
inadequate training
87575 (a) (g)+
Medical Care: inappropriate, incorrect, lack, neglect,
112
87702.1
didn’t obtain, failure to observe, recognize,
87591 obs
cared for
87578(a)(5),
Personal Rights: restraint/s, lack of dignity, lack of
113
87572 all
information, physical abuse, unable to use
87573 phone
phone
87576
Food Service: Unsafe practices, inadequate amounts of
114
food stores, insufficient portions
87580 cov.
Personnel: abuse, coverage, work schedules
115
87572 PR
1151
87564 reqt
Administrator or management failures, lying, false
87112 false cl
claims, Powers of atty, taking $$ out of facility,
87227 POA +
no accounting of $$
1152
87219
Uncleared personnel in facility issues related to DOJ
clearances.
1153
87565 (a)
Inadequate number of staff
(table continues)
111
Table 31. (continued)
CELL NAME/Title
1154
1155
1156
116
117
118
1181
119
120
121*
87565 (d)(3)
87565 (c)
1569.69
87566
87569 med ass
87582 TB
87587 reappra
87113
87561 transf
87222 POO
87721 exem
87227 (g) $
87570 rec.
87571
87568
87577
87578 (a)(5)(a)
87583preadmit
87588document
87584 ADLs
87583.1 needs
87229 cap
87110 amb st
87582 ret
122*
123*
210
87579
87590
87691
211
87692
212
87220
87221
87689
87691
87724
87691
87691(e)(2)
87724
87725 advert
213*
214*
215*
310
311
87703
312
87701
CODES
Non-English Speaking Staff
No or inadequate staff training
Staff records missing, files unavailable for review, file
retention, Medical, criminal docs, tb tests
Residents - Lack of complete medical assessments,
failure to have medical reports, reappraisal/
updates, tb tests
Failure of facility to report required incidents, events to
CCLD, plan of operation approvals, requests
for exemptions, waivers, transferability,
ownership changes
Resident records: incomplete, missing, off-premises,
roster
Admissions Agreement other than missing (118)
Personal Accommodations and services, 2/bedroom,
sink/toilet/bed/furniture, mattress, bedrails,
postural supports
Pre-admission appraisals, inadequate, missing, retaining
an individual not appropriate, document
findings, functional capabilities, service &
needs plan
Beyond Scope of License, over capacity, services
without waiver or exception, Hospice,
bedridden, ambulatory, N/A, acceptance and
retention limitations
Activities
Basic Services (ambient temp,
Maintenance and Operation: bathroom safety, physical
repair, broken furniture, insufficient furniture
Storage Space: unlocked or assessable toxics, and/or
sharps, firearms
Fire Safety: blocked exits, non-working smoke
detectors, FMC
Locks, Padlocks, Alarms off when should be on, Alarms
on when no alarms were approved
Cleanliness: Dirty, urine odor
Water temperature
Dementia Care: Lack of, inappropriate, inadequate staff
training, insufficient staffing levels to meet
needs of dementia residents, residents in need
of higher levels of care and failure to comply
with specific state requirements regarding care
of persons with dementia.
Oxygen administration, unsafe practice and storage of
tanks, lack of available skilled care, smoking,
signs
Prohibited/Restricted Health conditions (higher level of
care
(table continues)
112
Table 31. (continued)
CELL NAME/Title
313
314
315
316
317
318
319
320
321
410
411
412
413
416
500
V
W
ENFORCEME
NT ACTION
NATURE OF
ENFORCEME
NT
87701
87713
87707
87708
87710
87711
87716
87709
87704
87707
87705
87454
87223
87344
87581
87222, 87509
87589
CODES
Healing wounds
Managed incontinence, Deficiencies in use of
Diabetes, Deficiencies in use of
Injections, Deficiencies in use of
Hospice, Deficiencies in use of
Contractures, Deficiencies in use of
IPPB, Deficiencies in use of
Indwelling catheter, Deficiencies in use of
Colostomy, Deficiencies in use of
Firearms
Civil Penalty – authority for
Disaster/emergency plan
Inspection Authority
Night Supervision
Other, Eviction
2nd Violation Citation
600
700
$$ Abuse
701
Physical Abuse
800
Management Action
0 = N/A, None, Unk
1 = Yes
17 Rescission of Citations.
0 = N/A
1 = CP = Civil Penalty
Y = Amount of CP (-1.00 if penalty not known, or amt entered if data in file.
4 = Citation
5 = No enforcement where one could have occurred
6 = Corrective Action required but No Penalty or Citation
7 = Other Administrative Action (Non Compliance conference, office visit)
113
appendix g
sample lic 9099
114
Figure 11. LIC 9099.
115
appendix h
Crosswalk from pre-2008 regulations
to post-2008 regulations
116
Table 32. Cross Walk between Pre- and Post- 2008 Title 22 Regulation Numbers
WAS/OLD
IS/NEW
Unchanged
Unchanged
Unchanged
Unchanged
87113
87114
Article 1
87100
87101
87102
Article 2
87105
87106
87107
87108
87109
87111
87236
87112
Definitions and Forms
General
Definitions
Description of Forms
License
License Required
Operation without a License
Exemption from Licensure
Integral Facilities
Transferability of License
Continuation of License Under Emergency
Conditions or Sale of Property
Conditions of Forfeiture of a License
Posting of License
Applicant/Licensee Mailing Address
Nondiscrimination
87115
87117
87118
87233
87234
Application of License
Licensing Fees
Application Review
Capacity
Withdrawal of Application
Resubmission of Application
Provisional License
Denial of Initial License
87218
87224
87228
87229
87230
87235
87231
87340
Fire Clearance
Fire Safety
Limitations - Capacity and Ambulatory
GoverningSBody
87220
87689
87110
87560
87113
87114
87118
87119
87120
Article 3
87155
87156
87157
87158
87159
87161
87162
87163
Article 4
87202
87203
87204
87205
Posting of License
Applicant or Licensee Mailing Address
Nondiscrimination
Repealed
Repealed
Application Procedures
Application for License
Licensing Fees
Application Review
Capacity
Withdrawal of Application
Resubmission of Application
Provisional License
Denial of License Application
Operating Requirements
Fire Clearance
Fire Safety
Limitations - Capacity and Ambulatory
S
Accountability of Licensee Governing Body
Advertisements and License Number
False Claims
Plan of Operation
Program Flexibility
87111
87112
87222
87116
87206
87207
87208
87209
87560(c )
87561
87223
87562
87225
87211
87211(c )
87212
87213
87215
Definitions - Forms
Transferability
Continuation of License Under Emergency
Conditions/Sale of Property
Conditions for Forfeiture of a RCFE
License
Reporting Requirements
Disaster & Mass Casualty Plan
Finances
Commingling of Money
Unchanged
Unchanged
87102
Advertisements and License Number
False Claims
Plan of Operation
Program Flexibility
Reporting Requirements
Emergency Disaster Plan
Finances
Commingling of Money
(table continues)
117
Table 32. (continued)
WAS/OLD
Bonding
Safeguards for Cash Resources, Personal
Property and Valuables of Residents
IS/NEW
87226
87216
87227
87217
Theft & Loss
Planned Activities
Resident Councils
Requirements for Emergency Adult
Protective Services Placements
87227.1
87579
87592
87218
87219
87221
87593
87222
Relocation of Resident - General
Eviction Procedures
87342.1
87589
87223
87224
Article 5
Maintenance & Operation
Alterations to Existing Buildings or New
Facilities
Personal Accommodations and Services
Resident and Support Services
Storage Space
Telephones
Motor Vehicles Used in Transporting
Residents
87691
87303
87686
87305
87577
87690
87692
87573
87574
87307
87308
87309
87311
87312
Criminal Record Clearance
Criminal Record Exemption
87219
87219.1
Administrator - Qualifications and Duties
Administrator Certification Requirements
Administrator Recertification
i
Denial or Revocation of a Certificate
87564
87564.2
87564.3
Article 6
87355
87356
Article 7
87405
87406
87407
87564.4
87408
Forfeiture of a Certificate
Personnel Requirements - General
87564.5
87565
87409
87411
Incidental Medical & Dental Care
87575(f)(4)
87411(c )1
87566
87580
87581
87412
87413
87415
Personnel Records
Personnel - Operations
Night Supervision
Article 8
Acceptance and Retention Limitations
General
Pre-Admission Appraisal - General
Medical Assessment
87582
87567
87583
87569
87452
87455
87456
87457
87458
Bonding
Safeguards for Resident Cash, Personal
Property and Valuables
Theft & Loss
Planned Activities
Resident Councils
Requirements for Emergency Adult
Protective Services Placement
Relocation of Resident
Eviction Procedures
Physical Environment and
Accommodations
Maintenance & Operation
Alterations to Existing Buildings or New
Facilities
Personal Accommodations and Services
Resident and Support Services
Storage Space
Telephones
Motor Vehicles Used in Transporting
Resident
Background Check
Criminal Record Clearance
Criminal Record Exemption
Personnel
Administrator-Qualifications and Duties
Administrator Certification Requirements
Administrator Recertification Requirements
Administrator Certificate Denial or
Revocation
Administrator Certificate Forfeiture
Personnel Requirements - General
Personnel Requirements - General
(Training)
Personnel Records
Personnel- Operations
Night Supervision
Resident Assessments, Fundamental
Services and Rights
Renumbered to Section 87756
Acceptance and Retention Limitations
Evaluation of Suitability for Admission
Pre-Admission Appraisal
Medical Assessment
(table continues)
118
Table 32. (continued)
WAS/OLD
Functional Capabilities
Mental Condition
Social Factors
Reappraisals
Basic Services
Incidental Medical & Dental Care
Observation of the Resident
Resident Participation in Decision making
Personal Rights
AHCD, RFRM, DNR Forms
IS/NEW
87584
87585
87586
87587
87590
87575
87591
87583.1
87572
87575.1
Documentation and Support
Resident Records
Admission Agreements
Register of Residents
87588
87570
87568
87571
Food Services
87576
Health & Safety Protection
Automated External Defibrillators
Personal Assistance and Care
Allowable Health Conditions and the Use
of Home Health Agencies
General Requirements for Allowable
Health Conditions
Incidental Medical & Dental Care
Restricted Health Conditions
General Requirements for Restricted
Health Conditions
Prohibited Health Conditions
Incidental Medical Related Services
i
Department Review
Oxygen Administration & Gas & Liquid
Intermittent Positive Pressure Breathing
(IPPB) Machine
Colostomy/Ileostomy
Enema and/or Suppository and Rectal
Impaction Removal
Indwelling Urinary Catheter/catheter
Procedure
Managed Bowel and Bladder Incontinence
Contractures
87459
87461
87462
87463
87464
87465
87466
87467
87468
87469
Article 9
87505
87506
87507
87508
Article 10
87555
Article 11
Functional Capabilities
Mental Conditions
Social Factors
Reappraisals
Basic Services
Incidental Medical and Dental Care Services
Observation of the Resident
Resident Participation in Decision Making
Personal Rights
AHCD, RFRM, DNR Forms
Resident Records
Documentation and Support
Resident Records
Admission Agreements
Register of Residents
Food Services
General Food Services Requirements
Health-Related Services & Conditions
87700
U/C
87575.2
87578
87605
87606
87607
87608
Health & Safety Protection
Care of Bedridden Residents
Automated External Defibrillators (AEDS)
Postural Supports
Allowable Health Conditions and Use of
Home Health Agencies
87702
87609
87702.1
87611
General Requirements for Allowable Health
Conditions
87575(f)(4)
87701.1
87411(c )1
87612
87704.2
87613
87701
87721
87722
87703
87704
87615
87616
87617
87618
87619
87705
87621
87706
87622
87707
87623
Personnel Requirements - General
Prohibited Health Conditions
General Requirements for Restricted Health
Conditions
Prohibited Health Conditions
Exceptions for Health Conditions
Departmental Review of Health Conditions
Oxygen Administration - Gas & Liquid
Intermittent Positive Pressure Breathing
(IPPB) Machine
Colostomy/Ileostomy
Fecal Impaction Removal, Enemas, and/or
Suppositories
Indwelling Urinary Catheter
87708
87709
87625
87626
Managed Incontinence
Contractures
(table continues)
119
Table 32. (continued)
WAS/OLD
Diabetes
Injections
Protective Supervision (Obsolete)
Healing Wounds
Facility Hospice Care Waiver
Hospice Care for Terminally Ill Residents
Health Condition Relocation Order
Resident Request for Review of Health
Condition Relocation Order
IS/NEW
87710
87711
87712
87713
87716.1
87716
87701.3
87628
87629
87630
87631
87632
87633
87637
87701.5
87638
Administrative Review - Incidental
Medical Services
Repealed
Repealed
87720
87639
87714
87715
Care of Persons with Dementia
Advertising Dementia Special Care,
Programming, and/or Environments
Training Requirements if Advertising
Dementia Special Care, Programming
and/or Environments
Advertising Dementia Special Care,
Programming and/or Environments as of
July 3, 2004 - Repealed and Obsolete
87724
87725
87640
87641
Article 12
87705
87706
87725.1
87707
Article 13
87344
87755
87345
87452
87756
(87756(c-3)
Licensee Complaints
Serious Deficiencies - Examples
Follow-up Visits to Determine Compliance
Penalties
Administrative Review - General
Denial or Revocation of License for
Failure to Pay Civil Penalties
Unlicensed Facility Penalties
Unlicensed Facility Administrative Appeal
87343
87451
87453
87454
87455
87757
87758
87759
87761
87763
87455.1
87766
87457
87458
87768
87769
Article 14
87775
87777
87342
87346
Article 15
Initial Certification Training Program
Approval Requirements
Healing Wounds
Hospice Care Waiver
Hospice Care for Terminally Ill Residents
Health Condition Relocation Order
Resident Request for Review of Health
Condition Relocation Order
Administrative Review - Health Conditions
Dementia
Care of Persons with Dementia
Advertising Dementia Special Care,
Programming and Environments
Training Requirements if Advertising
Dementia Special Care, Programming and
Environment
87725.2
Inspection Authority of the Licensing
Agency
Evaluation Visit
Deficiencies in Compliance
Revocation or Suspension of License
Exclusions
Diabetes
Injections
87730
87785
Enforcement
Inspection Authority of the Licensing
Agency
Evaluation Visit
Licensee Complaints
Serious Deficiencies - Examples
Follow-up Visits to Determine Compliance
Penalties
Appeal Process
Denial or Revocation of License for Failure
to Pay Civil Penalties
Unlicensed Facility Penalties
Unlicensed Facility Administrative Appeal
Administrative Actions - General
Revocation or Suspension of License
Exclusions
Administrator Certification Training
Programs - Vendor Information
Initial Certification Training Program
Approval
(table continues)
120
Table 32. (continued)
WAS/OLD
IS/NEW
Denial of Request for Approval of an
Initial Certification Training Program
87730.1
87786
Denial of ICTP
Revocation of an Initial Certification
Training Program
87730.2
87787
Revocation of ICTP
87731
87788
CEU Vendor Requirements
87731.1
87789
CEU Approval Requirements
87731.2
87791
Administrative Review
87731.3
87792
Denial of Request for Approval
87731.4
87793
Revocation of CEU Program
Continuing Education Training Program
Vendor Requirements
Continuing Education Training Program
Course Approval Requirements
Administrative Review of Denial or
Revocation of a Request for an Approval
of a Continuing Education Course
Denial of a Request for an Approval of a
Continuing Education Training Program
Revocation of a Continuing Education
Training Program