Overview of Deficiency Citations in Florida Assisted Living Facilities
Why do some assisted living facilities keep getting cited—but never improve? In Florida, repeat violations reveal ongoing care failures that put residents at risk. These persistent problems often go unchecked for years. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Hari Sharma to explore the troubling trends in Florida ALFs and what can be done to hold them accountable.
Sharma:
If people have cognitive impairments, reside in that facility, if they don’t have a license for it, they shouldn’t be having those individuals in the assisted living. And if they have it, they’ll be cited for it. They’re complying with the regulations that are meant to protect the older individuals from potential problems with their safety and quality of life.
Intro
Schenk:
Hey out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I will be your host for this episode. Today we are talking about surveyor processes and deficiencies in. Facilities, specifically assisted living facilities in Florida. And the reason why is because we have Dr. Hari Sharma PhD on he wrote a fantastic article called The Prevalence and Persistency of Deficiency Citations in Florida Assisted Living Facilities.
And that sounds dry, but for nerds like me it’s interesting and he has a lot of good. Points that have come through from this article. His kind of, what his research has found. So we have a, we have an excellent conversation. With Hari about the surveyor process and how that process can be improved and why it’s there in the first place in reality.
We have Dr. Hari Sharma on. Dr. Hari is an assistant professor of health management and policy at the University of Iowa. He holds a PhD in health economics from the University of Chicago. His research focuses on access, quality and financing and post-acute and long-term care, including nursing, home closures, and rural access.
He also studies nursing home workforce issues such as staffing, turnover, and injuries. His work is supported by. Several federal agencies. It was a typo. It said, supported by every federal agency, but that’s not true. It’s several federal agencies, including the NIH and the CDC, and we’re so happy to have on Dr. Hari, welcome to the show.
Sharma:
Thank you.
What is a deficiency citation?
Schenk:
So the first question that I have for you before we get into the nuts and bolts of your research is when we say a deficiency citation, what are we actually talking about? What is that?
Sharma:
Every healthcare provider has to follow a set of rules and regulations. And, these might be at the federal level or at the state level. So anytime, states are finding deficiencies in terms of the facilities not complying with the rules and regulations. They have the ability to cite facilities for not complying with those rules and regulations.
So facilities, in the case of assisted living, are defining the rules and regulations that each assisted living facility has to comply with. And any time, the state inspectors find that they’re not complying with those they issue citations and we call them deficiency citations.
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Who investigates deficiencies in Florida Assisted Living Facilities?
Schenk:
And you mentioned a surveyor or an investigator but who are these people, like typically, I guess in Florida? Who are these individuals that are going and looking into whether or not a Florida regulation and assisted living facility has been violated?
Sharma:
So they have in Florida, it’s under the.
Agency for Healthcare Administration. And they have a division of, health quality assurance and, they are responsible for licensure and regulations. So facilities, so the inspectors are part of the state agency. And sometimes, some of these individuals could be employed by the state.
Sometimes they could be third party contractors that do the survey of the healthcare provider. So it could be a different set of individuals that might be inspecting these facilities depending on how the state chooses to organize some of these things. But.
Overall, they are trained to look into whether the facilities are complying with the rules and regulations and they should be issuing citations based on the compliance history.
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Schenk:
How often are these surveyors going to assisted living facilities in Florida to inspect what’s going on? Is this just something that’s like once or twice a year? Is it when somebody calls them to come?
Sharma:
So it be a combination of things. So they have set rules in terms of how frequently these facilities are to be inspected, and that depends on the type of facility, the compliance history of that facility, right? Typically. Every assisted living facility has to be inspected every two years.
But then if they have certain kinds of licenses, and they’re caring for sicker individuals, they might be inspected a little more frequently. If there is a complaint, then, these inspectors are supposed to go in and review the evidence regarding the complaint as well. So again, this.
Minimum is every two years. There could be more frequent citations or inspections depending on whether there is a complaint or, if there are, they’re providing more care for residents, so that means they need to be surveyed more frequently.
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Schenk:
Can you tell us again before we get into the kind of the substance of your research, but like how you get into researching?
Assisted living facilities in Florida deficiencies and things like that. Walk us through like how you got into that and what led you to your, to the paper that we’re talking about today.
Sharma:
I’ve been looking at nursing home quality for quite a while for about, 10 over 10 years now.
And, over time, one of the things that we’ve seen as, there’s a lot of regulations with respect to nursing homes and, these are regulations at the federal level, at the state level. And what’s happening in the US over time is, we’re trying to get away from institutional living for older individuals, now we’re trying to see if we can provide them a little bit more of a home-like environment.
We’re. Encouraging individuals to live in assisted living, live in homes and communities. And it’s to provide them a better home-like environment as long as they can. So I, certainly we’ve seen, more and more people living in assisted living facilities and also getting home-based care, and I wanted to examine.
The type of, quality of care that’s in, in these facilities the level of inspections that happen, the type of deficiencies that are found and whether, facilities are complying with them in the true sense, right? You’d expect that, anytime you’re cited for an issue, you fix it for that year, but you don’t repeat it in the next cycle again, right?
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Typically, anytime state inspectors find deficiencies, facilities are required to fix it within a certain period of time. Now the challenge is, what happens if they repeat it? So then, it depends on the type of violation they have. If it’s, very serious violation, there’s a potential that the facility would be terminated from the state license.
But for the most part, for a lot of the things that. They are cited for that, which does not happen. Again, that’s how I got into this and I’m expanding my work more into assisted living and also, looking into adult daycare centers, which are also getting more popular with both the policy priorities and also the preferences of older individuals to stay in the communities.
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How common are the deficiencies related to quality of care?
Schenk:
What are some of the more common deficiencies? Is that related to quality of care that you saw in your research?
Sharma:
In terms of resident resident care we frequently find issues around resident care, right? So are they getting it. Help with the ADLs that they need.
Are they getting the medications on time, the appropriate dosing of medications? Do these facilities have appropriate or sufficient staff? So if they are providing, let’s say, nursing services, it has to be a nurse that provides those services, not anybody else. And if they are assisting with medications, it would be someone that is familiar with the medications, if it’s an injection that they need someone, certified to provide injections to patients or residents in this case.
A lot of the times the things we are seeing are. Related to resident care related to providing appropriate medications. We’re also seeing a little bit more around. Background check screenings that these facilities are required to do.
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Especially in Florida, it’s actually getting pretty stringent over time in terms of facilities required to undergo background checks, and processes for potential employees. And also, some of the other things are also there in terms of emergency management.
A little bit of traction over time and whether facilities are prepared for it or not. Records, right? So are they, keeping appropriate records for individuals admissions, are they admitting the right kind of individuals that can actually live in these facilities? So if people have cognitive impairments, can they still reside in that facility?
If they don’t have a license for it? They shouldn’t be having those individuals in assisted living, and if they have it, they’ll be cited for it. So again, overall, is to make sure that they’re complying with the regulations that are meant to protect the older individuals from potential problems with their safety and quality of life.
If you are an operator or family member, explore our guide to meeting Georgia assisted living regulations to stay compliant.
Schenk:
Did your research uncover anything with respect to the method in which the surveyor. Uncovers that information like, so the surveyor walks in, doesn’t know anything. Okay. Like how do they know where to get the data? Who are they talking to?
Sharma:
So some of this depends on why they are there, right?
Sometimes if you are there for the standard inspections, which are mentioned earlier, every 24 months, at a minimum, they should be inspected once, right? So if that is the case, then they’re going in with an open mind, reviewing everything that is in there, right?
But if it’s a complaint inspection, then they’re not looking for everything. They’re looking for that specific. Issue that they got a complaint about. So it dep again, it depends on what that is, right? So if it’s the initial license, then they gotta go and inspect everything.
For legal information and advocacy services, visit the Schenk Nursing Home Abuse Law homepage.
If it’s monitoring, it’s gonna have slightly different variations depending on the intent of the inspection. But typically, there are. Allowed to look at every record that they are supposed to maintain, right? So fiscal facilities are to maintain every record around admissions, residents, the staffing, the training of the staff that are in those facilities.
Medication records for each resident, anything that’s coming from their providers in terms of, the needs of these residents, the ADLs, and, the type of help they need with their everyday life. So they’ll and they’re also talking to the residents and staff, by looking at this aggregate of evidence, then they try to determine if the facility is in compliance with any particular set of regulations.
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There are, if you look at the regulations for assisted living in Florida. You’ll see over 180 pages of regulations and inspectors are supposed to look at each and every one of those. And if they find that the facility is not in compliance and there are instructions for surveyors to look at specific things.
So describe for example, with respect to admissions, what are the things they should be looking at? Depending on what kind of facility that is, and if they find that anything is not in compliance, then. They’re supposed to discuss that further with the staff and then determine whether it merits a deficiency citation.
Schenk:
Do you, so the surveyors are working from lemme say, so if you’re a longtime listener or viewer of this podcast, you know that we refer to the watermelon book, which is the manual that the surveyors for nursing homes use to to do the same process that Hari just described. Is there a similar, we’ll say a watermelon book in quotation marks for Florida, for the surveyors, for assisted living.
Sharma:
So they all have a specific set. And it’s very specific, it tells the inspectors to look at records for residents, talk to residents. If you know that’s. Deemed appropriate. So it’s, again it’s that same manual that you find for nursing homes.
It’s a little bit longer. And it’s a lot more detailed. But again, I’ve read these manuals. Several times. And it’s amazing how much detail there is both in terms of expectations and also what the surveyors are supposed to look at in terms of, how do they identify whether the facilities are in compliance or not, right?
So a lot of the time it involves both. Checking the records and also talking to residents and staff.
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Are larger assisted living facilities more likely to be cited?
Schenk:
In your research, did you have anything, or did you have an opinion now about trends with these deficiencies? Is there a certain change now? Don’t name any chains, but do you find any association between the citations and perhaps the ownership of the facilities?
Sharma:
I think one of the things that we do see often and it’s not limited to assisted living, is, profit status definitely plays a role in the number of citations we see facilities having, right? For-profit facilities tend to have, higher number of citations, and that’s true for assisted living as well as nursing homes more broadly, and not just in Florida, but it’s across the board in the country.
And, part of the worry for us and also residence is, is there a compromise with respect to quality because of the profit incentive? And that’s the one concern that I have. Doesn’t mean all for-profit facilities are providing some poor quality of care but maybe in some cases there are making these choices where.
They’re prioritizing a little bit more on the profit side than on the resident quality side. So with respect to ownership, that’s one of the things that we’ve seen is, they tend to have slightly higher number of citations. And it’s fairly broad in terms of where these citations are.
It’s across the board for the most part.
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Why do some Florida assisted living facilities keep getting cited?
Schenk:
Did, after conducting your research, do you have any opinion about whether or not the survey or process itself could be better or not? Like in other words like. Maybe the surveyors should be there for a longer period of time, like days and days, or maybe they should have access to more information, et cetera.
Sharma:
I think my bigger concern is what do we do once you find citations and, how does that. Change the structure and processes in that facility. Following that survey, everybody makes mistakes, right? It’s not the initial mistake, hopefully it’s not threatening to the residents and, it’s still not a serious issue.
Anytime there’s a mistake that’s found, our goal is to correct it and not make that mistake again. And so for that, I think the inspectors are doing a fine job in identifying issues that are in that facility and they’re required to correct them and they are correcting them in that moment.
But next year, again, if you’re getting cited for that same issue again, then it’s inefficient, right? One, we’re wasting resources trying to get to the same issue again and again. And two, if they’re not fixing it, then what are we doing it?
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Schenk:
The, theoretically, isn’t it the case that if they’re cited for something a second time or a third time or a fourth time aren’t there in, in Florida, isn’t there like an administrative board that would cite them or fine them or things like that? Or is that just not happening?
Sharma:
Some of these things depend on the severity of the issue, right? So if it’s threatening the safety and quality of the resident, then they might be fine, $500, a thousand dollars. That’s the other issue I, I was gonna talk about is that, these fine fines are just not enough to incent change, right?
So if it’s a major structural change that they’re required to fix. Then they’re better off not fixing it and getting cited every time and paying the fines. I think we wanna approach it from two different angles, right? One is enforcing regulations and making sure that the fines are.
Enough to incent these facilities to change their processes. And two, also thinking about ways to encourage them to do these things, right? So is there an incentive that we wanna provide to these facilities to improve quality of care? And part of it is also to do with the reimbursements, right?
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So you know how much we are providing to these facilities to take care of residents. Is that enough? And a lot of the time, especially with Medicaid and, sometimes Medicare as well, it’s hard for these facilities to provide quality care and staff them to provide quality care because there’s just not enough resources and that’s the struggle that we have.
Is, our facilities doing enough from their side. And two, are we providing them with enough resources to actually provide quality care to the residents. So it’s a combination of those two things. In general, I think Florida has done a decent job and kind of. Making some of these data sets public for researchers like myself to look into quality of care.
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And I think, a lot of the other states should follow that in terms of making some of these data sets public so that researchers can look at the data, trying to understand the extent to which there are quality of care issues. And two. When we find something, it’s on the policymakers to address the things that we find to improve the quality and safety of these residents.
The work that I did in terms of looking at deficiencies in Florida assisted living is one of the very few articles that are out there that have looked at this issue. I think, because we are expanding more and more into home and community based settings. I think it’s on the states to encourage researchers to take the dataset that they have and try to find ways to improve on the quality of care that’s being provided to these residents.
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Schenk:
Very well said. Hari, thank you so much for coming on the show and sharing your knowledge with us.
Sharma:
Thank you Rob. It was a pleasure to talk to you.
Schenk:
Folks, I hope that you found this episode educational. If you have an idea for a topic that you would like for me to discuss, please let me know.
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Hari Sharma’s Contact Information: