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    Abuse and Neglect in Long-Term Care Facilities: The regulatory agency's responsibility

    Wisconsin's Department of Health and Family Services has various tools to ensure that entities and individuals provide appropriate care to vulnerable individuals. Through its regulatory approval, inspection, and investigations, the department oversees the operation of health care entities and service providers, investigates allegations of individual caregiver misconduct, and provides technical support and coordinates its efforts with other county and local agencies that protect and advocate for the disabled elderly in Wisconsin.

    Linda Dawson

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    Wisconsin LawyerWisconsin Lawyer
    Vol. 77, No. 8, August 2004

    Abuse and Neglect in Long-Term Care Facilities:
    The Regulatory Agency's Responsibility

    Wisconsin's Department of Health and Family Services has various tools to ensure that entities and individuals provide appropriate care to vulnerable individuals. Through its regulatory approval, inspection, and investigations, the department oversees the operation of health care entities and service providers, investigates allegations of individual caregiver misconduct, and provides technical support and coordinates its efforts with other county and local agencies that protect and advocate for the disabled elderly in Wisconsin.


    elderly man by Linda Dawson

    The scenario repeats all too often. With little more than a few weeks' training, a certified nursing assistant (CNA) assigned to provide direct care to 15 or more frail, elderly residents with dementia or other conditions requiring skilled nursing care in a nursing home is stretched too thin. A confused resident repeatedly pushes the call light because he wants to use the bathroom. His care plan requires that two persons assist with transfers. Several residents on the unit are calling out for attention; other CNAs are busy; the nurse is attending to another resident's medical needs. The CNA has to make a decision. If the CNA doesn't respond promptly, she could be disciplined. Should she wait for assistance as required by the resident's plan of care or try it alone? After all, the resident doesn't weigh much. The CNA knows that weakened residents who can no longer support their weight are hard for one person to safely handle. If she decides to try the transfer alone, rather than wait or use the equipment as required, a fall could result. Brittle bones break easily against hard surfaces in bathrooms or on floors. A broken hip in a frail, elderly resident often leads to the person's untimely death.

    Who is responsible for the person's injury or death? Is it the CNA who took a chance in spite of the known risks or the employer who did not provide adequate training, staffing, or supervision to ensure that a resident's care plan was followed? Administrators and direct care staff in Wisconsin's residential health care facilities make difficult choices every day. The consequences of those choices can be deadly. Should someone be held accountable for these decisions? If so, who and to what extent? Who decides?

    Wisconsin's Department of Health and Family Services (DHFS) has various tools to ensure that entities1 and individuals provide appropriate care to vulnerable individuals. Through its regulatory approval, inspection, and investigations, the DHFS oversees the operation of health care entities and service providers. The DHFS also investigates allegations of individual caregiver misconduct, including abuse or neglect of clients or misappropriation of clients' property. Finally, the DHFS provides technical support and coordinates its efforts with other county and local agencies that provide protection and advocacy services to the disabled and elderly in Wisconsin. These tools enable the DHFS to: 1) ensure the protection of disabled and vulnerable clients across their lifespan; 2) hold entities accountable for the care provided; 3) hold caregivers accountable for intentionally or negligently disregarding their obligations and duties to those who rely on them for care; and 4) ensure that protection and advocacy systems effectively and efficiently meet the needs of Wisconsin's most vulnerable citizens, regardless of where they reside.

    This article outlines the DHFS's regulatory options and the potential consequences for health care providers and individual caregivers who neglect, abuse, or financially exploit individuals residing in or receiving care from Wisconsin's regulated residential care facilities. It also identifies resources for lawyers who may be representing entities, individual caregivers, or clients affected by the care of others.

    Regulatory Approval, Survey, and Complaint Investigations: Focusing on Residential Care Facilities

    The Survey, Inspection, and Investigation Process. Within the DHFS, the Bureau of Quality Assurance is responsible for the uniform, statewide licensing,2 inspection, and regulation of nursing homes,3 community-based residential facilities, adult family homes, resident care apartment complexes, hospitals, and hospices.4 Under its oversight authority, the DHFS determines whether these entities are in compliance with applicable state laws and federal regulations.

    The DHFS oversees the operation of entities initially through the license application process, determining whether an applicant is "fit and qualified" to operate an entity in Wisconsin. The DHFS then monitors conditions in the entity and compliance with applicable state and federal law through unannounced compliance inspections or surveys. The DHFS also investigates complaints concerning conditions, care, or treatment. These inspections and investigations have three major components: 1) direct observations of care; 2) interviews; and 3) review of pertinent records or documents. During the survey or complaint investigation process, the DHFS looks for evidence that an entity is ensuring that a resident's rights are protected and the resident is free from abuse and neglect.5 The complainant6 may remain anonymous. Providers are prohibited from retaliating or discriminating against any employee who provides information to the DHFS or the long-term care ombudsman.7

    Throughout the process, informal meetings between entity administrators and the department occur. At the end of the survey or investigation, an exit conference is held during which any suspected violation is explained and the entity is given an opportunity to respond. If the DHFS determines that a violation of applicable regulations or laws has occurred, the entity is served with a written notice of the violation.

    Opportunities exist for further review and appeal. Nursing homes may request an informal dispute resolution conference, which provides an opportunity to present additional information. After considering the new information, the DHFS may retain, amend, or withdraw the violation.

    When the DHFS establishes a violation of one or more requirements, state sanctions or federal remedies may be imposed. The type and level of sanctions imposed by the DHFS and, as applicable, federal regulators, depend on the scope and severity of the violation, the economic benefit to the entity, the extent of harm to the entity's clients, and the entity's compliance history. In most cases, the entity has the right, under chapter 227 of the Wisconsin Statutes, to appeal a violation and imposed sanction.8 Notwithstanding an appeal, the entity is expected to immediately correct identified violations and to ensure that the violations will not recur.

    Factors Contributing to Abuse, Neglect, and Exploitation in Facilities. The DHFS's goal in overseeing health care entities is to reasonably and effectively encourage entities to comply with applicable regulations so that individuals receive the care they need and deserve. Most entities provide quality care; however, some do not. There are several reasons care might decline in an entity.

    Expanded residential settings. Nursing homes are serving a more challenging population. Individuals are increasingly choosing to remain in their homes with assistance or reside in assisted living settings. An individual's increasing needs for care and nursing services can be met through the continuum of available programs and settings. However, the changing care needs of individuals makes the provision of highly-skilled, quality care a challenge for entities and their staff. The unintended result can be resident neglect or harm.

    Financial difficulties. Financial difficulties often provide a warning sign of future care problems. Workforce shortages, staff turnover, and increasing costs for supplies and services present significant problems for entities seeking to sustain and improve quality. Operators face hard decisions when money is tight. A recent report to Congress found "'strong and compelling' evidence that nursing homes with a low ratio of nursing personnel to patients were more likely to provide substandard care."9

    Stressed or abusive staff. When an entity lacks sufficient trained staff to provide care, residents are harmed, often seriously. Nursing home residents require high levels of individualized care. A CNA with responsibility for too many residents may not be able to properly attend to a resident's special dietary needs, causing significant weight loss, dehydration, choking, or aspiration pneumonia. A few minutes are too long for many residents to wait to be able to go to the bathroom. When they can no longer wait for assistance, residents may get up by themselves, fall, and break a bone. A broken leg can be fatal. When residents are bed-bound, bedsores (decubiti ulcers) may develop. Bedsores can rapidly worsen, leading to sepsis. Too often, inadequate care leads to premature and painful death.

    Neglect is prevalent when staff are stressed or overwhelmed. CNAs often are called on to work double shifts. Pool (temporary) staff cost more, lack training in an entity's procedures, and are less familiar with residents' needs. Tired and undertrained staff react inappropriately to challenging situations, for example, by rushing, ignoring, or otherwise neglecting residents. Many acts of abuse by a caregiver are not the result of stress; rather they are often acts of power and control. Regardless of the cause, in each case these individuals fail in their duty to the vulnerable persons who rely on them for compassionate care.

    Lack of understanding or awareness. The DHFS has increasingly emphasized through training sessions and publications that entities are responsible for preventing and reporting client abuse and neglect and misappropriation of client property. In 2002, more than 140 violations were issued to nursing homes related to abuse, neglect, and misappropriation of resident property - a 43 percent increase since 1999. Many of these incidents were self-reported, reflecting a better identification of prohibited conduct.

    Sexual abuse is one form of abuse that now is being reported more often. In one reported case, a resident with dementia repeatedly attempted to kiss, touch, and climb into bed with another resident. Staff dismissed the conduct, stating, "Boys will be boys!" In another incident, in which a family member committed a sexual assault, the resident's physician excused the conduct: "Some families are like that."

    Increased awareness about sexual assault has led to increased reporting. The DHFS, representatives from the Wisconsin Coalition Against Sexual Assault (WCASA), aging and disability organizations, law enforcement, and providers developed a protocol for responding to sexual abuse of a resident.10 In spring 2004, the WCASA offered training sessions across the state for advocates, providers, and law enforcement on improved responses to reports of sexual assault.

    Effective Prevention Efforts. Regardless of the setting, entities must ensure residents' protection. Critical to the residents' protection is prevention. An entity's prevention approach is signaled first by the training provided for staff regarding its policies and procedures and by the provision of supervision to ensure that all employees follow the entity's policies and procedures. A culture of safety and responsibility actively encourages prompt reporting of any suspected mistreatment of clients. All residents, employees, family members, and visitors should know how to report to the entity suspected mistreatment of a client by anyone. Perpetrators are less likely to act when they know that all eyes are watching all the time. When a report is made or an injury is discovered, the entity must take whatever steps are necessary to protect clients from further harm. Entities provide additional, necessary protections when they promptly and thoroughly investigate and evaluate injuries of unknown origin and pursue and report to the DHFS, law enforcement, or the appropriate regulatory agency all incidents of suspected client abuse, neglect, and exploitation.

    Caregiver Misconduct: Focusing on Individuals

    The Wisconsin Caregiver Law. In 1997, in response to concerns about the backgrounds of individuals who were caring for its most vulnerable citizens, Wisconsin passed a comprehensive caregiver law.11 The law requires thorough background checks at least every four years of the following: individuals employed by or under contract with the entity who have direct, regular contact with clients served by the entity; persons who are not clients of an entity but who reside at the entity ("nonclient residents"); and persons seeking regulatory approval. The background check includes determining whether the individual has any criminal convictions, findings of caregiver misconduct, or limitations on any credentials the person holds.

    Individuals with certain serious criminal convictions12 are barred from contracting with, being employed by, being licensed to operate, or being able to reside (other than as a client) in regulated entities. Additionally, individuals with findings by a governmental agency of misconduct, for example, abuse or neglect of a child or a client or misappropriation of a client's property, are similarly barred. Barred individuals are eligible for regulatory approval or employment only after satisfying the DHFS that they are rehabilitated.13 Additionally, entities are urged to determine whether other convictions are "substantially related" to employees' duties or positions.14 Failure to comply with these requirements or knowingly submitting false information may result in sanctions against the entity or individual?.15

    Reporting and Investigating Caregiver Misconduct. Another part of the caregiver law involves reporting allegations of misconduct by caregivers, investigating the reports, and protecting the due process rights of the accused caregivers.16 The DHFS maintains the Wisconsin Caregiver Misconduct Registry, an official record of persons found to have abused or neglected a client or misappropriated a client's property.17

    Any person may report suspected misconduct by a caregiver to the DHFS.18 When an entity becomes aware of an allegation of caregiver misconduct, it must take steps necessary to ensure that clients are protected from further harm while a determination is pending.19 Then the entity must conduct a preliminary investigation. The entity must report the alleged misconduct within seven calendar days from the date the entity first knew or should have known about the misconduct if the entity determines that: 1) the conduct meets a definition of misconduct; or 2) the conduct could, after further investigation by an investigating agency, meet the definition; or 3) caregiver misconduct cannot be affirmatively ruled out.20 Entities are required to report to the appropriate agency21 incidents of misconduct. Intentionally failing to report allegations of caregiver misconduct may result in penalties, including forfeitures of up to $1,000, license revocation, and notice in a local newspaper of the failure to act.22

    When the DHFS receives a report of caregiver misconduct, it conducts an investigation and coordinates its efforts with other agencies as appropriate.23 Because many incidents of alleged misconduct involve possible criminal activity, the DHFS works closely with local law enforcement and the Wisconsin Department of Justice.

    After completing its investigation, the DHFS provides written notice of its determination to the accused caregiver.24 The accused caregiver is given an opportunity to appeal a substantiated determination.25 If the DHFS's determination is confirmed, the caregiver's name is placed on the Wisconsin Caregiver Misconduct Registry.

    Identifying Misconduct: Abuse, Neglect, and Misappropriation of Property. Three types of misconduct are defined in chapter HFS 13 of the Wisconsin Administrative Code: abuse; neglect; and misappropriation of property. Abuse includes acts that are intended to cause harm, sexual assault, the forcible administration of medication without lawful authority, and harassment.26 Examples of abuse substantiated by the DHFS include massaging a resident's genitals, slapping a resident, dragging a resident on the floor causing rug burns, and repeatedly mocking a resident. In November 2003, out of 87 allegations received, 28 (34 percent) involved allegations of physical or sexual abuse.

    Although neglect can lead to serious harm to clients, neglect is often overlooked or minimized by entities and caregivers. Neglect includes an individual's act or omission that causes or could reasonably be expected to cause harm to a client or that disregards a client's rights or a caregiver's duties.27 Most commonly, neglect cases involve caregivers who, despite training, fail to perform their duties - for their own convenience and to the client's detriment. Examples of neglect substantiated by the DHFS include failure to supervise a client with a history of wandering (he was found dead after leaving the facility), leaving clients alone in a van while the caregivers attended a movie, and leaving a nonverbal quadriplegic resident unattended for hours (resulting in an injury after a fall).

    The final form of misconduct is misappropriation of a client's property.28 The most common form is theft of personal property, such as money, jewelry, prescription drugs, or other items of value. Other forms include theft by fraud or misrepresentation, theft by a trustee, identity theft, uttering a forged document involving the property of a client, or the fraudulent use of a client's financial transaction card. Examples of misappropriation substantiated by the DHFS include theft of medications, use of a client's credit card to purchase personal items, use of the client's telephone to make calls to 900 numbers, theft of jewelry, taking funds for personal use that were intended as payment for services, and "borrowing" a large amount of cash from a client with no intent to repay the client.

    Lack of consent is an element of some forms of abuse (for example, sexual assault) and theft. Although it may be difficult to determine whether a person has given consent or is capable of giving consent, a key question is whether the individual is capable of understanding the nature and consequences of the act. In some cases involving sexual contact, consent is not a required element.29

    In 2002, the DHFS received 1,209 reports of caregiver misconduct. Of those, 538 involved abuse, 392 involved neglect, and 272 involved misappropriation. Sixty-five were outside of the DHFS's jurisdiction either because the caregiver involved was regulated by another department (for example, the Department of Regulation and Licensing) or because the entity was not regulated under the caregiver law. The DHFS completed 851 investigations in 2002. As a result of those investigations, 164 individuals' names were placed on the caregiver misconduct registry.30

    Dispositions in Caregiver Misconduct Cases. Caregiver cases can be resolved in several ways. Most cases result in a finding of misconduct. Federal law requires the DHFS to place a finding of misconduct on the Wisconsin Caregiver Misconduct Registry when a conviction results from an offense committed in a federally certified nursing home.31 A conviction in a state court for the conduct constitutes "substantial evidence" against the caregiver.32 In some neglect cases, the caregiver may request that the finding be removed from the registry after one year. In other cases, the DHFS may enter into deferred finding agreements with accused caregivers.33

    Disclosure of Information Concerning Findings. Almost 1,000 names are now listed on the registry. When the DHFS receives an inquiry about an individual, the DHFS may disclose only whether the individual's name is on the misconduct registry and, if listed, whether a rebuttal statement exists.34 Except as authorized, the DHFS may not release any information from a report when an allegation is not substantiated. Once placed on the registry, the individual's name remains listed unless the finding is reversed or the person dies.35

    Demonstrating Rehabilitation. Barred caregivers - those with certain serious convictions or findings - must demonstrate that they are rehabilitated before they are eligible for consideration for regulatory approval to operate an entity, for employment, or for nonclient residency.36 To obtain approval, applicants must submit information requested by the DHFS.37 The information submitted is reviewed at a panel meeting.38 The applicant is invited to appear.

    After reviewing the information, panel members determine whether sufficient information was presented to show that the applicant is rehabilitated.39 The panel considers factors related to the applicant's personal development and history, the position the person is seeking, and the offense. The panel may approve the applicant, defer a decision for up to six months, or deny the approval.40 Once granted, approval may be suspended and withdrawn if an applicant commits a new offense or violates a condition of approval.41 Entities must verify an individual's approval status when conducting background checks.

    Collaboration Among Other Systems

    Wisconsin has long been a leader in elder abuse prevention and intervention. Despite this history, the number of reported incidents of elder abuse across Wisconsin jumped 15 percent from 2001 to 2002.42 The increase may be due to increased public awareness about elder abuse and related crimes. As discussed above, regulatory oversight, entity practices and policies, and individual background checks are three methods of protecting vulnerable individuals from harm. However, one of the most effective prevention and intervention methods, regardless of where a person resides, is communication and collaboration among agencies.

DawsonLinda Dawson, U.W. 1984, deputy chief legal counsel for the Wisconsin Department of Health and Family Services, supervises the DHFS legal staff, litigates cases including caregiver abuse and regulatory violations in long-term care facilities, and is assigned to special projects, such as the DHFS Regulatory Re-Engineering project, the Caregiver Law, and, most recently, as cochair of the Adult Protective Services modernization project. She also has provided investigative skills training for many of the DHFS staff and has been a certified trainer under the Violence Against Women Act. In addition to her law degree, Dawson holds a B.S. and M.S. in behavioral disabilities.

    There are many resources dedicated to preventing abuse and neglect of vulnerable adults and the elderly. The DHFS's Bureau of Aging and Long Term Care Resources provides support for and consultation to county agencies and providers. Section 46.90 of the Wisconsin Statutes requires that counties provide a published phone number for reporting elder abuse and investigating allegations of abuse, neglect, or financial exploitation. In addition, county and tribal human service agencies support county efforts in the area of adult protective services. A 2002 Joint Legislative Council Special Committee, cochaired by Sen. Robert Wirch and Rep. Suzanne Jeskewitz, examined chapter 55 and related statutes (chapters 51 and 880 and section 46.90 of the Wisconsin Statutes) and recommended changes codifying recent court decisions.43 The committee also accepted many of the recommendations made by the DHFS's Adult Protective Services Modernization Project. Changes to the guardianship laws are being separately pursued. The federal Elder Justice Act, if passed, may provide additional resources and support. The National Clearinghouse on Abuse in Later Life, through the Wisconsin Coalition Against Domestic Violence, has been a national leader in developing theories, training sessions, and policies on the overlap between domestic violence and elder abuse. Another state resource is the Board on Aging and Long Term Care's Ombudsman program. The Ombudsman's program offers many services, including complaint investigation, mediation, training, and education.44

    In 2002, the DHFS provided additional direct service funding to counties that developed elder abuse interdisciplinary teams (I-Teams). I-Teams provide a forum to address difficult situations involving self-neglect, neglect, abuse, and exploitation. Similar models have been used successfully in addressing domestic violence and child abuse and neglect. I-Teams include representatives from law enforcement, health care, faith communities, financial institutions, the county's lead elder abuse agency, and domestic abuse and sexual assault service providers. Facilitated by the I-Teams, these providers and agencies can more effectively coordinate their prevention and intervention efforts and identify strategies for challenging cases. In addition, lead elder abuse agencies are required to have in place memorandums of understanding with law enforcement,45 to define roles and expectations in responding to situations of neglect, self-neglect, abuse, or exploitation.

    There are many other collaborative efforts in place or emerging to combat abuse and neglect of adults at risk of abuse, neglect, or exploitation. Representatives of the U.S. Attorney's Office, the Wisconsin Department of Justice, the DHFS, the Ombudsman program, and aging and disability groups meet regularly. The purpose of these meetings is to share information and to identify cases involving caregiver or entity abuse and neglect that may be prosecuted criminally or civilly through the False Claims Act.

    It is important that agencies continue to coordinate efforts and improve resources. Information must be provided to visitors, residents, family members, and providers on how to identify potential physical, emotional, and financial harm and report it. The DHFS goal is to end mistreatment of Wisconsin's most vulnerable citizens. The regulatory efforts focused on systems and individuals described in this article are critical means to achieving that goal.


    1In this article, the term "entity" means a facility or program regulated, licensed, certified, or approved by the DHFS to provide care or treatment services to clients.

    2Through its regulatory process, the DHFS licenses, certifies, registers, or approves various entities that provide care and treatment services to clients.

    3The term "nursing homes" includes facilities for the developmentally disabled, also referred to as intermediate care facilities for persons with mental retardation (ICFs-MR).

    4The provisions regarding the DHFS authority over these providers is found in Wis. Stat. chapter 50.

    5Wis. Stat. § 50.09. Among other things, persons receiving care or treatment services from regulated health care settings have the right to be free from physical, sexual, and mental abuse and neglect; the right to be treated with dignity; the right to prompt and adequate care based on their individual needs; and the right to have their personal property protected and to be free from financial exploitation.

    6Complaints may be filed by anyone, most commonly by family members, residents, or clients served by the entity, entity staff, visitors, or the state's Ombudsman or other advocates. The Board on Aging and Long Term Care's Ombudsman program is described more fully later in this article.

    7Wis. Stat. § 50.07(1)(e).

    8For an explanation of the chapter 227 appeal process by an administrative law judge, see Sean Maloney, A Primer on Administrative Hearings, 76 Wis. Law. 28 (July 2003).

    9Robert Pear, 9 in 10 Nursing Homes Lack Adequate Staff, Study Finds, N.Y. Times (Feb. 18, 2002).

    10The protocol encourages entities to designate a contact person with specialized training to support the sexual assault victim and protect the victim and others from further emotional or physical harm. For more information about domestic violence and sexual assaults in facility settings, see DDES Information Memo 2004-03.

    11The caregiver law is found in Wis. Stat. sections 50.065 (health care entities) and 48.685 (child care entities).

    12Serious convictions include convictions of homicide, felony battery, sexual assault, abuse of vulnerable adults, patients or residents, and physical or sexual assault of a child. See Wis. Admin. Code ch. HFS 12 app. A.

    13For more information about the caregiver law and the rehabilitation review process, go to the DHFS Web site.

    14In determining whether a crime is "substantially related," entities are encouraged to review the factors related to the person, the job, and the offense identified in Wis. Admin. Code section HFS 12.06. Certain convictions, such as misdemeanor battery or disorderly conduct, require employers to examine the factual basis to determine whether the act is substantially related. See Wis. Admin. Code ch. HFS 12 app. A.

    15Wis. Admin. Code § HFS 12.05.

    16Wis. Admin. Code § HFS 13.01.

    17Wis. Admin. Code § HFS 13.04(1).

    18Wis. Admin. Code § HFS 13.05(4)(a). A copy of the reporting form may be found at: http://dhfs.wisconsin.gov/forms/DDES/DDE2447.pdf. PDF 80 KB

    19Wis. Admin. Code § HFS 13.05(2).

    20Wis. Admin. Code § HFS 13.05(3)(a).

    21Wis. Admin. Code section HFS 13.05(3) requires that caregiver misconduct be reported to the DHFS, except that an entity must report an incident to the Department of Regulation and Licensing (DRL) if it involves a person who holds a DRL credential, and incidents of child abuse or neglect must be reported to the county department of social or human services. Entities also may report suspected crimes to local law enforcement.

    22Wis. Admin. Code § HFS 13.05(3)(e).

    23Wis. Admin. Code § HFS 13.05.

    24Wis. Admin. Code § HFS 13.05(6)(c).

    25Wis. Admin. Code § HFS 13.05(6)(c)2.b.

    26Wis. Admin. Code § HFS 13.03(1).

    27Wis. Admin. Code § HFS 13.03(14).

    28Wis. Admin. Code § HFS 13.03(12).

    29For example, Wis. Stat. section 940.225(2)(g) prohibits an employee of an adult family home, community-based residential facility, inpatient health care facility, or state treatment center from having sexual contact or sexual intercourse with a person who is a client of the entity.

    30To determine whether an individual is listed on the Wisconsin Misconduct Registry, contact www.promissor.com or call (877) 224-0235.

    3142 C.F.R. § 483.13(c)(1)(iii).

    32Wis. Admin. Code § HFS 13.05(6)(d)1.

    33In deferred finding agreements, a finding is not placed on the registry pending successful completion of the conditions of the agreement. Conditions often include satisfactory job performance, successful completion of training or education in an area related to the incident, a written statement about the impact of the conduct on residents, and no further reported incidents of alleged misconduct within a time specified.

    34Wis. Admin. Code § HFS 13.05(8).

    35Wis. Admin. Code § HFS 13.05(8)(c).

    36Approval must be granted by the regulatory agency or tribe that regulates the entity. For the majority of applicants, that agency is the DHFS. See Wis. Admin. Code § HFS 12.12(1), (2).

    37Wis. Admin. Code § HFS 12.12(3). An applicant must complete a form required by the DHFS and include supporting information about the barring offense; a statement explaining why approval should be given; personal reference checks from individuals and professionals; evidence of successful completion of probation or parole; evidence of subsequent training, education, or community service; criminal history, including information about other offenses; and pending criminal or civil actions.

    38Wis. Admin. Code § HFS 12.12(4)(c).

    39Wis. Admin. Code § HFS 12.12(4).

    40Wis. Admin. Code § HFS 12.12(5). When an approval is denied, the applicant may appeal the decision.

    41Wis. Admin. Code § HFS 12.12(6).

    42Wisconsin Report on Elder Abuse, 2002.

    43Additional information is available at www.legis.state.wi.us/lc/2002studies/CH55/index.htm

    44Wisconsin Board on Aging and Long Term Care, Ombudsman Program.

    45Wis. Stat. § 46.90(3)(a).