A
n indicator that consumers can use to evaluate an RCFE's regulatory compliance is the citation. In this issue, we do a deeper dive into citations, contextualizing them from policy and consumer's points of view. Then we give you data about citation counts by facility capacity, as an overlay.
Consumers call wanting to know whether a facility is 'good' or 'bad'. As Chris Murphy's article tells us, CARR doesn't characterize facilities; instead we look at objective information, including the citation count, on the state's transparency website, before we relate factual information to consumers.
Christina Selder's article, "It's an A. It's a B. It's Inconsistency." discusses the variability in state inspectors' citation patterns. That variability creates uneven enforcement across facilities, and undermines the regulatory authority of CCLD, in CARR's view.
Rebecca Ruiz crunched numbers for us, giving us her findings. She points out that citations provide a snapshot of a facility's regulatory performance, and should be considered by a consumer as but one indicator among many of quality of care.
If you know someone who could benefit from the information in this newsletter, we hope you will share it with them.
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How Many Citations are Too Many?
by Chris Murphy, MS
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Consumers call CARR asking if one assisted living facility or another is a “good” place. As is our practice, we do not characterize assisted living facilities, but we
do
give the inquiring consumer factual information about the facility they've asked about.
When CARR receives an inquiry, our first stop is the state’s transparency website
[1]
to access the profile the state has created for that licensed assisted living facility. Once on that facility’s page, we click the “Citations” tab. On this page we can see the total number of citations (both Type As and Bs) the facility has received over five years.
We tell the consumer how many citations the facility has; then to put the citation quantity in context, we share with the consumer our ‘rule of thumb.’ Our method isn’t exact, fool-proof or even scientific; rather, it’s an
informal guide
we’ve developed over the past eleven years of reading facilities’ public records:
- 0 to 5 citations. Definitely worth giving the facility a second look.
- 5 to 6 citations in a five-year period isn’t a bad bet – worth learning more about.
- 7 to 12 citations . . . it’s getting iffy.
- 13 citations or more? Somebody really isn’t paying attention to the details of good resident care, or doesn’t understand the regulations surrounding the assisted living care model.
So a facility that has zero citations is the best, right? It depends. A newly-licensed facility may not have any citations because it hasn't been open long enough to receive an annual state inspection. But finding a facility that’s been open for five or more years, with zero citations – now there’s a facility that moves to the top of the list.
How does the consumer know how long the facility has been licensed? In the upper right corner of the facility profile, the state tells the consumer when the facility was licensed. Do the math, check out the total citation count, and you the consumer can narrow your choices quickly and easily.
If you want to learn about the citations a facility has received, you can move over to the ‘Reports’ tab, opening each hyperlinked document. There, you’ll be able to read the inspection or complaint report, what the state’s findings were. In the process, you’ll learn more about how the facility operates. You will also be able to see the nitty-gritty about the citation, assessing for yourself how well the facility stacks up to your expectations.
As Rebecca's article below notes, the number of citations is important, but is only one measure of facility performance and quality. There are many other factors to consider, as she points out. But knowing how to narrow your options gives you a short list of facilities for further consideration.
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It’s an A. It’s a B. It’s Inconsistency.
by Christina Selder, MS
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The state inspectors responsible for enforcement in assisted living facilities are called Licensing Program Analysts or LPAs. The Evaluator Manual is the step-by-step instructional guide given to LPAs to guide their evaluations of facility compliance and other licensing requirements. CARR often uses the reference materials and evaluation tools provided in the Evaluator Manual to improve our understanding of the state’s enforcement practices. One area, in particular, is to explain the variability seen in LPAs’ citation patterns.
The Evaluator Manual’s guide for
Facility Evaluations
offers LPAs the following instructions when determining which type of citation to issue to a facility—Type A, Type B, or Type C:
- Type A citations are violations of the regulations that, if not corrected, have a direct and immediate risk to the health and safety of residents.
- Type B citations are violations of the regulations that, if not corrected, could become an immediate risk to the health and safety of residents.
- Type C citations are violations of the regulations that do not present an immediate (Type A) or potential (Type B) risk to the health or safety of residents. No citations are issued for these technical violations.
Depending on the LPA’s interpretation of what constitutes an “immediate” or “potential” risk, a Type A, Type B, or no citation will be issued to a facility.
This level of discretion frequently results in different facilities being held accountable in different ways.
The citation for water temperature compliance offers the most basic example of this inconsistency.
For example, for
Facility #374602806
, one LPA issued a Type B citation for water temperature registering at 135.5 degrees (regulatory maximum is 120 degrees). Whereas for
Facility #374603279
, another LPA issued a Type A citation for water temperature registering at 121-137 degrees.
This same variability can be seen for more serious compliance issues as well, such as failure to provide services or personal rights violations.
It is the Department of Social Services’ position that the ability to exercise discretion in the field is the best way LPA’s can navigate their role as both enforcer and advisor to facilities. However, it is this same case-by-case approach that threatens to undermine their credibility as an effective oversight agency. The solutions to address this variability are complex, but at the state-level include better training for LPAs and the creation of new evaluation tools.
All this to say that these circumstances directly influence the compliance histories consumers have access to and reaffirms CARR’s view that citations (types, counts, averages, etc.) serve as only one indicator of many consumers should use when evaluating facilities.
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Facilities by the Numbers
by Rebecca Ruiz, Data Analyst
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We took a closer look at San Diego’s 588 licensed assisted living facilities thanks to the information provided by California’s Department of Social Services’ website. Specifically we looked at the number of citations facilities had received over the past 5 years. A facility's citation history can tell you a lot about how well a facility is operated.
Here are some of our findings:
113 facilities in San Diego County don't have any citations. That's almost 20%! And another 40% of facilities have fewer than 6 citations.
However, almost 30% of facilities have 10 or more citations. CARR's view is that facilities with 10 to 13 citations over a 5-year period may be problematic. CARR recommends the compliance histories of those facilities be reviewed carefully to determine if, in the consumer's eyes, the facility can ensure resident health and safety.
An interesting trend we found when looking at citation averages was as a facility’s capacity increased, their citation average also increased. Citation averages for facilities based on their size are:
- 6.6 citations for 1-6 bed capacity
- 6.9 citations for 7-15 bed capacity
- 7.0 citations for 16-49 bed capacity
- 7.9 citations for 50-99 bed capacity
- 8.5 citations for 100+ bed capacity
It is important for families to remember that citation histories should be considered snapshots of facility competence regardless of the number of citations. While the number of citations for a facility is important, many other factors go into how well a facility will care for a loved one: the administrator’s knowledge and dedication, caregiving staff turnover, and staff-to-resident ratios will all affect how well seniors will be treated and how quickly staff responses will be.
When considering facilities to tour, however, reviewing the citation history counts can help families narrow their choices of communities to a manageable number without setting foot on the property or speaking to a salesperson.
If you, or someone you know, needs help accessing or understanding a facility’s compliance history please give us a call. We are happy to help.
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Public records don't harvest themselves
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CARR's annual intern program with SDSU costs us about $3,000. And it's because we have an exceptional intern program that CARR has been able to amass about 40,000 public documents on assisted living facilities in California. We are able to collect and understand what's in the public records in ways nobody else in California can.
But - it costs money. $3,000 a year in fact.
Can you help us?
Your contribution will help us continue to collect public records on California's licensed assisted living facilities.
No donation is too small. And if you give us your name, you will receive a heart-felt thank you and an acknowledgement from us that can be used for IRS purposes.
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