Compliance reviews of Assisted Living Residences

Learn more about the purpose, findings, and responses of biennial compliance review inspections of Assisted Living Residences (ALR).

Table of Contents

Purpose and content of compliance reviews

Before an ALR can be certified, the EOEA will preform a compliance review to ensure the ALR is meeting standards. Compliance reviews take place at least once every two years. Additionally, a compliance review can be conducted if an ALR is suspected to be violating assisted living regulations. Upon completion of the compliance review, the ALR is eligible for certification or re-certification. 

Compliance reviews must include:

  • A review of the operating plan for the ALR
  • Inspection of common areas in the ALR
  • Inspection of the room of a resident (with the resident's consent)
  • Examination of any document in a resident's record (with the resident's consent)
  • Refusal to provide the EOEA access to residence, staff, and documents is a valid basis to suspend, revoke, or deny an application for certification or re-certification. 

The following compliance review forms are required to be completed:

Employee File Review Form

Resident Documents Review Form

Employee Training Record Form 

Compliance review findings and responses

After conducting a compliance review the EOEA must summarize their findings in writing. If an ALR passes the compliance review, they will receive a notice of compliance within 10 days. If the ALR does not pass the compliance review, they will receive a notice of noncompliance within 10 days. This notice will inform the ALR of what rules or regulations they have broken and how to fix them in order to pass the compliance review.  

Responding to a notice of noncompliance

The applicant has ten days to respond to the notice of noncompliance with either agreement or disagreement to the EOEA's findings. If the applicant agrees with the EOEA they must submit a written plan on how they will fix the compliance issues. The following must be included in the written statement:

  • A specific plan of what will be or was done to correct the problem
  • A description of what will be done to prevent recurrence of this problem or problems of this type
  • Who will monitor the problem and ensure it is corrected and will not reoccur
  • The date on which the problem will be fixed

Corrective actions to a failed compliance review

If an ALR receives a notice of non compliance the EOEA can require the residence to take the following corrective actions:

  • Stop enrolling new residence
  • Lower the amount of Residence served
  • Make staffing changes
  • Take additional training

Factors that the EOEA may consider when determining corrective actions:

  • Any occurrence of noncompliance
  • The risk that the instances of noncompliance present to the health, safety, and welfare of residents
  • The nature, scope, severity, degree, number, and frequency of the noncompliance
  • The applicants failure to fix the noncompliance
  • The result of past corrective action plans

  

Suspension or refusal to issue or renew certification

The EOEA can suspend or refuse any certification or re-certification of an ALR if the applicant:

  • Refused to follow applicable laws, regulations, and corrective orders
  • Lied on any required reports
  • Refused to submit any required paperwork
  • Refused to admit an authorized member of the EOEA to inspect the ALR
  • Did not obtain certification before opening 

If the EOEA decides to refuse or revoke the applicants certification, the applicant will be ineligible to apply for certification for 5 years. Additionally, the EOEA can revoke, suspend, or refuse to renew a residence's certification without notice if the residence is in severe non compliance. 

Please refer to the Assisted Living Regulations  for further details.

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