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DQA Quarterly
Information Update

October 2012

PDF Version of this month's Quarterly Update (PDF, 298 KB)

NEW THIS ISSUE

REGULAR FEATURES


NEW THIS ISSUE

FOCUS 2012: Register Now!
Bureau of Education Services and Technology

FOCUS 2012: Special Session
November 28, 2012

"The Art and Science of Fall Prevention"

FOCUS 2012: Conference
November 29, 2012

"Mission Possible!"

Conference information and online registration is located at: http://www.uwsp.edu/conted/ConfWrkShp/Pages/Focus2012.aspx

The Wisconsin Department of Health Services (DHS), Division of Quality Assurance (DQA), is pleased to announce the 11th annual conference for health care providers and DQA staff on November 28 and 29, 2012 at the Kalahari Convention Center in Wisconsin Dells. The Focus 2012 Conference is being developed in collaboration with health care provider and provider association representatives.

At FOCUS 2012, attendees will have access to leading experts in the health care field, the chance to network with others, and an opportunity to visit the numerous exhibit booths.

This year, the Special Session will focus on Fall Prevention. This topic is receiving special attention in order to increase both awareness of the issue and efforts to reduce the high incidence of falls in Wisconsin. This special session is intended for staff from assisted living facilities, facilities serving people with intellectual disabilities, home health agencies, hospice providers, hospitals, and nursing homes, as well as occupational therapy and physical therapy professionals, pharmacists, medical directors of nursing homes, and the Division of Quality Assurance.

The Special Session keynote speaker will feature Aleksandra Zecevic, PhD, Assistant Professor at Western University, London, Ontario. Her presentation is titled, "Understanding Falls and Falls Prevention". This presentation will provide an overview and scope of the problem, falls in diverse health care settings, injuries, cost, and prevention. Dr. Zecevic will also present a plenary session titled, "The CSI of a Fall --- A Systems Approach to Investigating Causes of Falls". This session will cover systems issues vs. person centered approaches, why falls assessments are not enough, safety culture, and how falls can help improve health care safety.

The theme of the FOCUS 2012 Conference is, "Mission Possible!" The goal of the conference is to provide attendees with as many tools as possible to improve the health and safety of Wisconsin residents living in health care facilities. This conference is intended for staff from assisted living facilities, facilities serving people with intellectual disabilities, nursing homes, and the Division of Quality Assurance.

The keynote speaker is Dr. David Gifford, MPH, American Health Care Association and National Center for Assisted Living Senior Vice President of Quality and Regulatory Affairs. The title of his presentation is "Quality Improvement: Role of Healthcare Leadership and Regulations to Achieving High Quality Outcomes." Dr. Gifford will discuss the roles leaders play in guiding their clinical staff to achieve quality care and comply with health care regulations, using real case scenarios from different health care settings related to patient safety.

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Wisconsin Act 120 Effective July 1, 2012
Office of Caregiver Quality

This Act enables veterans to request consideration of their military training, education, and experience to satisfy the nurse aide requirements if they can demonstrate substantial equivalency of that training, education, and experience to the nurse aid requirements.

Wisconsin State Statute 146.40 was revised to include the following:

Any relevant education, training, instruction, or other experience that an individual has obtained in connection with any military service, as defined in s. 111.32(12g), counts toward satisfying the requirement to complete the state-approved training program under this subsection, if the individual or the nursing home or intermediate care facility demonstrates to the satisfaction of the department that the education, training, instruction, or other experience obtained by the individual is substantially equivalent to the state-approved training program.

In order to assist the department in determining if training is substantially equivalent to the nurse aide training requirements found in the Code of Federal Regulations CFR 42 part 431 and Wisconsin Administrative Rule DHS 129, the military service member will be required to submit the following documentation:

  • Service School Academic Reports including course start/end dates, course of study, and grade;
  • Certificates of Training for specific programs completed such as apprenticeships, specialization courses, or hands-on training courses;
  • Training documentation signed by your Unit's Training Non-Commissioned Officer, and;
  • A written personal narrative as to why you feel your military education, training, and/or experience has prepared you for this profession.

A second provision under Wisconsin's Act 120 allows an active duty service member or their civilian spouse who was unable to practice under their nurse aide certification during the period of active duty to extend their nurse aide certification for 180 days after the date of discharge and to renew that certification to the next biennium without completing the required re-testing.

For further information please contact the Office of Caregiver Quality at (608) 261-8319 or DHSCaregiverIntake@wi.gov.

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Update on HHA CASPER Reports
Bureau of Education Services and Technology

CMS has recently added two 'claim-based' measures to all home health agencies' (HHA's) CASPER reports. The two claim-based measures are: Acute Care Hospitalization and Emergency Department (ED)-use Without Hospitalization.

The claims-based 'ED-use Without Hospitalization' measure has already replaced the OASIS-based 'ED-use Without Hospitalization' measure in CASPER; the OASIS-based version is no longer reported. However, the OASIS-based 'Acute Care Hospitalization' measure will continue to be reported in CASPER along with the claims-based report on hospitalizations.

The two new claim-based measures are both currently available in the CASPER reports. To see your HHA's new claims-based measures/results when acquiring your CASPER reports, select the 'report category' of 'OASIS-C Quality Improvement' and then you may select either the 2-bar or 3-bar 'Risk Adjusted Outcome Report' based upon your personal preference. When you print either of these reports, the first four pages of the report will be the OASIS-driven outcome results that you are already familiar seeing. The final, fifth page contains the new claims-based reports. At this time, the only claims-based data that is available is from April 2011 through March 2012; so, even if you request data for a different time period, page 5 of the report will automatically default to these dates.

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OASIS-C Assessment Instrument
Bureau of Education Services and Technology

Many of you have noticed that the OASIS-C dataset for conducting comprehensive assessments (CAs) has an expiration date of July 31, 2012. "Not to worry," says CMS. You can continue to use the current OASIS-C dataset because CMS has already submitted the renewal of the document to the federal Office of Management and Budget (OMB) for approval. Thus, the expiration date is null and void until the OMB approval of the request for extension is complete.

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Release of OASIS Q&As
Bureau of Education Services and Technology

In July, the newest quarterly OASIS Q&As were released by CMS and the OASIS Certificate and Competency Board (OCCB). These two groups collaborate to release new Q&As each quarter. Each HHA would be wise to follow these releases because the new 'guidance' that comes through becomes the newest 'OASIS rules' and is effective immediately upon release. The July Q&As can be found at https://www.qtso.com/hhadownload.html. The next quarterly release is scheduled for mid-October.

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CMS-Sponsored OASIS Training Videos
Bureau of Education Services and Technology

CMS recently released two additional new web-based trainings for OASIS, as promised. Both videos address areas of common misconception among home health agency (HHA) staff responsible for performing the OASIS comprehensive assessment (CA) on HHA patients. The new modules cover Care Planning and Intervention and the Neuro/Emotional/Behavioral domain questions. Be sure to print out the posted slide sets before watching the training videos.

You can find these training videos and corresponding slide sets on this webpage: http://surveyortraining.cms.hhs.gov/pubs/ProviderTraining.aspx

The initial 'Medication Module' for OASIS-C training is also posted on this same web-page. In addition to the above training videos, CMS sponsored three earlier OASIS-C training videos on the YouTube website that were related to specific M-questions in the OASIS CA. The 'location' of these videos has changed since the original broadcast; you can find these videos now at the addresses listed below. They are excellent for any staff new to OASIS or as a refresher:

1. Accurately Responding to the Plan of Care Synopsis question (M2250): http://www.youtube.com/watch?v=H7mdobdIXr4&feature=relmfu

2. Accurately Responding to the Intervention Synopsis question (M2400): http://www.youtube.com/watch?v=XrPJ85GQJVg&feature=relmfu

3. Accurately Responding to the Falls Risk Assessment question (M1950): http://www.youtube.com/watch?v=gUFeQZWQycY&feature=relmfu

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HHA Face-To-Face Encounters Affecting OASIS Assessments
Bureau of Education Services and Technology

Along with the requirement for federally certified HHAs to be accountable that their patients receive a physician face-to-face (F2F) encounter, HHAs have experienced that some encounters don't occur within the timelines that Medicare requires. When this encounter occurs late, it leaves the HHA scrambling for 'what to do' with their OASIS comprehensive assessments (CAs) that have already been transmitted to the state. CMS has issued some guidance on this issue.

HHAs that have not kept current in how the timeliness of their patients' F2F encounter affects OASIS CAs will want to check out the OASIS Quarterly Q&As from April of this year located here: https://www.qtso.com/download/hha/CMS_OAI_1stQtr2012_QAs_04_18_2012.pdf

An additional clarification that CMS made after the publication of these Q&As is that when a HHA needs to modify their SOC date due to a late F2F encounter, you need to calculate the 'closest' OASIS assessment to the new eligible SOC date. This refers to OASIS assessments both before and after the new SOC date; days are counted chronologically and before or after are acceptable.

In addition, CMS released a Medicare Learning Network (MLN) article for physicians on the F2F encounter in May; however, it is an excellent source of information for HHAs as well. Locate the article here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1219.pdf

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HHAs and HHCAHPS Reporting
Bureau of Education Services and Technology

The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) is a survey tool that collects patient feedback on topics important to consumers of home care, such as the HHA's communication skills, patient education received, customer service, etc. To learn more about HHCAHPS, visit: https://homehealthcahps.org/Home.aspx.

It is in a HHA's best interest to participate in HHCAHPS so that the HHA may receive its full annual Medicare payment update. Medicare certified HHAs that have been collecting HHCAHPS patient surveys can now see the results posted on Home Health Compare (HHC). CMS plans to refresh the HHCAHPS satisfaction data on HHC every four months.

CMS' goal in publicly posting both quality measures and satisfaction results is to create incentives for HHAs to improve the quality of their patient care. Additionally, public reporting increases accountability by increasing transparency. Visit Home Care Compare's website to check out the comparative public reporting available on any certified HHA's quality measures and satisfaction results: http://www.medicare.gov/homehealthcompare/search.aspx.

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OASIS Security Reminder
Bureau of Education Services and Technology

Due to recent security incidents where HHA providers sent privacy data unencrypted through e-mail, CMS wants to remind all HHAs that sending sensitive information via e-mail is a violation of CMS policy, and could be deemed as a potential HIPAA event. All Medicare organizations have Conditions of Participation (CoPs) that require them to abide by HIPAA rules.

CMS policy states: "All personally identifiable information (PII), whether for a CMS employee, provider, or beneficiary, shall not be transmitted via e-mail unless it is sent as an attachment that has been appropriately encrypted using CMS-approved encryption software." CMS suggests the publication, "Guidelines on Electronic E-mail Security," as a good place to obtain recommended security practices for handling sensitive information via e-mail. Find the publication here:
http://csrc.nist.gov/publications/nistpubs/800-45-version2/SP800-45v2.pdf.

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Delay in Implementation of ICD-10 Coding
 Bureau of Education Services and Technology

On August 24th, HHS Secretary Kathleen Sebelius announced a final rule which included the announcement of the official one-year postponement in ICD-10 implementation from October 1, 2013 to October 1, 2014. All HIPAA-covered entities must transition to ICD-10 coding. These code sets of medical diagnoses and procedures will include many new codes that improve the quality of information available for Quality Improvement strategies and payment purposes. This delay will give providers more time to prepare and test their systems for a seamless transition across all healthcare entities. Find more ICD-10 information from CMS here: http://www.cms.gov/Medicare/Coding/ICD10/index.html.

CMS had previously indicated that the next version of OASIS-C assessments, utilized by HHAs, was supposed to coincide with the transition to ICD-10 in October 2013. However, though already officially titled OASIS-C1, as of the submission of this article (mid-Sept.) there has been no word from CMS as to the anticipated update of OASIS-C to OASIS-C1.

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REGULAR FEATURES

Changes in DQA Staff

Bureau of Assisted Living (BAL)

Tom Redding, Health Services Specialist - Southeastern Regional Office

Tom Redding began his employment with SERO Monday July 30, 2012 and has been with DHS for a total of 25 years, mainly supporting children and adults with intellectual disabilities. Most recently, he was a QMRP/Program Coordinator for the Short Term Assessment Program at Central Wisconsin Center, and he has also worked as a QMRP at Southern Wisconsin Center and a Community Integration Program (CIP) Specialist. His educational background includes a B. S. degree in Therapeutic Recreation and master's level course work in Special Education.

Andrea Bauman, License/Permit Program Associate - Southeastern Regional Office

Andrea Bauman began her employment with SERO Monday September 24, 2012 in a position that has been vacant for two and a half years. Andrea comes to us from the Department of Motor Vehicles, where she has been a Field Service Agent for the past four years. She has a bachelor's degree in Social Work from Mount Mary College, as well as a Master's in Social Work (MSW) from UW-Milwaukee, with some great research and internship experience in gerontology/caregiving and disability advocacy and guardianship.

Bureau of Health Services (BHS)

Barbara Saar, QAPS - Clinical Laboratory Section

Barbara Saar retired from the CLIA (Clinical Laboratory) Program, Bureau of Health Services, effective September 10, 2012. Barbara's profession spans 40 years as a Medical Laboratory Scientist, certified with the American Society of Clinical Pathologists, including 15 years in DQA as a CLIA laboratory surveyor and Quality Assurance Program Specialist Senior (QAPS). Barbara's expertise is recognized nationally, as are her contributions to insure and promote the integrity of the CLIA Program in Wisconsin. While her contributions in public service are too vast to list, highlights include organization of the Midwest Consortium in 2012 and collaboration with the Division of Public Health to publish a report of the Clinical Laboratory Workforce Survey. Over the years, other state agency representatives have relied on Barbara's knowledge and expertise to administer their programs. Barbara's commitment to education and technical assistance has improved the quality of laboratory testing in Wisconsin and she has consistently gone 'above and beyond' to provide exemplary public service. She will be missed.

Until Barbara's position is filled, contact:
Cremear Mims, Director
Bureau of Health Services
(608) 264-9887
Cremear.Mims@dhs.wisconsin.gov

Sandra DeMars, Nurse Consultant 2 - Acute Care Compliance Section

The Bureau of Health Services welcomes Sandra DeMars as the new NC2 within the Bureau. Sandra comes to BHS from the Bureau of Nursing Home Resident Care, has her BSN in Nursing, and has many years of nursing and survey experience. She began her role in BHS on August 13th.

Bureau of Education Services and Technology (BEST)

Denise Torgeson, Nurse Consultant 1 - Education Services Section

Denise Torgeson recently moved within the Bureau into ESS and has assumed some new work tasks. She will have primary responsibility for review and approval of new and existing Traumatic Brain Injury units and ventilator programs; training and consultation responsibility for ambulatory surgery centers, rural health clinics and therapy providers; and will provide assistance in preparing and providing public health outbreak reports to DQA regional office staff and managers. She will also provide assistance on NH issues as requested. Prior to coming to the Bureau of Education Services and Technology, Denise was a nursing home surveyor in the Madison regional office.

Henry Kosarzycki, Engineer Consultant - Education Services Section

Henry Kosarzycki joined ESS on Aug. 20 as the lead engineer consultant (position formerly held by Bill Lauzon). Henry will have primary responsibility for training and consultation regarding life safety code regulations and related issues. Prior to coming to ESS Henry was an engineer surveyor in the Office of Plan Review and Inspection.

Michelle Doro, Nurse Consultant - Education Services Section

Michelle Doro resigned from her Nurse Consultant position (hospital emphasis), effective Aug. 24. Michelle has accepted a transfer to the Office of Inspector General.

Bureau of Nursing Home Resident Care (BNHRC)

Patricia Virnig, Regional Field Office Director - Southern Regional Office

Patricia Virnig is the newest RFOD in the BNHRC, SRO. Pat will begin her new duties effective September 23 and her first day in the office is scheduled for the 24th. Pat has worked for DQA for over 24 years and, in this time, Pat has held many positions --- all of which have helped prepare her to take on this new challenge. Pat has served as the Interim Director during Juan Flores' military deployments and as the RFOS for the SRO for over eight years. Among other things, Pat has helped conduct new surveyor training and enjoys working with the SRO DON council.

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DQA Numbered Memos (July, August September)

Access these memos via
http://www.dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm  or via individual providers' publications pages at http://www.dhs.wisconsin.gov/rl_DSL/ 

Memo No.

Title

Summary

Providers Affected

12-008

Heat Awareness

The purpose of this memo is to share a press release issued by the Department of Health Services on June 13, 2012 regarding the health risks associated with hot weather and to provide information about Heat Awareness.

Adult Day Care
Adult Family Homes
Ambulatory Surgery Centers
Certified Mental Health and AODA
CLIA-Certified Laboratories
Community Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Home Health Agencies
Hospices
Hospitals
Nursing Homes
Outpatient Rehabilitation Facilities
Personal Care Providers
Residential Care Apartment Complexes
Rural Health Clinics

12-009 MDS Section Q Referral to Local Contact Agency Process Program Update This memo describes changes made to the MDS Section Q referral process and revisions to the MDS 3.0 Section Q Referral form. Nursing Homes
12-010 Summary Survey Report - Due September 20, 2012 The purpose of this memo is to request hospitals that are accredited and deemed to meet the federal conditions of participation and submit a copy of the Summary Survey Report. Hospitals
12-011 E-SOD/e-POC Initiative, Provider Search Application, and Online Posting of SODs and POCs DQA is now prepared to extend this option to all provider types and facilities on a voluntary basis. Effective immediately, DQA will serve SODs to and accept POCs from all regulated providers using e-mail, with the exception of assisted living facilities (adult day cares, adult family homes, community-based residential facilities, and residential care apartment complexes), which will be included at a later date. Adult Day Care
Adult Family Homes
Ambulatory Surgery Centers
Certified Mental Health and AODA
CLIA-Certified Laboratories
Community Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Home Health Agencies
Hospices
Hospitals
Nursing Homes
Outpatient Rehabilitation Facilities
Personal Care Providers
Residential Care Apartment Complexes
Rural Health Clinics
12-012 Authentication of Physician Orders in Hospitals This memo supersedes DQA Memo 07-019 issued October 27, 2007 and repeals the statewide variance of Section DHS 124.12(b)(b)11, Wis. Admin. Code: Authentication of Physician Orders in Hospitals. Effective July 16, 2012, CMS regulations regarding authentication of verbal orders within 48 hours has sunset. Hospitals
12-013 Fire Watch, Fire Plan, and Fire Reporting Update The purpose of this memo is to provide information regarding the response to fire related emergencies in health care facilities. Adult Day Care
Adult Family Homes
Ambulatory Surgery Centers
Community Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Hospices
Hospitals
Nursing Homes
Residential Care Apartment Complexes
12-014 Adult Family Home Training - Revised Requirements The purpose of this memorandum is to identify and further clarify the training requirements for adult family home service providers and licensees. This memo also describes the sources of training that are acceptable to the Department. Adult Family Homes
12-015 Requirements Regarding the Confidentiality and Proper Disposal of Health Care and Related Records This memo reminds all health care providers of the statutory requirements regarding the confidentiality and proper disposal of heath care and related records containing protected health information. Adult Day Care
Adult Family Homes
Ambulatory Surgery Centers
Certified Mental Health and AODA
CLIA-Certified Laboratories
Community Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Home Health Agencies
Hospices
Hospitals
Nurse Aide Training Programs
Nursing Homes
Outpatient Rehabilitation Facilities
Personal Care Providers
Residential Care Apartment Complexes
Rural Health Clinics

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CMS Survey & Certification Letters (July, August, September)

Listed below are Survey and Certification (S&C) Letters distributed by the Centers for Medicare & Medicaid Services (CMS) during the last quarter. Please note that the CMS Internet site for reviewing all S&C memos is:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

S&C No.

Title

Summary

Providers Affected

12-37-NH Redesign Updates to the Nursing Home Compare Website CMS will launch a re-designed Nursing Home Compare website on July 19, 2012. Website will add new MDS 3.0 quality measures, detailed inspection reports (CMS 2567s), nursing home ownership information, and additional staffing data. Nursing Homes
12-38-NH Quality Assurance and Performance Improvement (QAPI) in Nursing Homes --- Activities Related to QAPI Implementation Section 6102(c) of the Affordable Care Act mandates CMS establish standards and provide technical assistance to nursing homes on the development of best practices relating to QAPI. This memo outlines several initiatives that CMS has put forth to implement these provisions. Nursing Homes
12-39-NH 2012 Centers for Medicare & Medicaid Services (CMS) Nursing Home Action Plan The 2012 Nursing Home Action Plan will be posted on the CMS website. Nursing Homes
12-40-NH Notice - Seventh Opportunity National Background Check Program Funding CMS will release a seventh solicitation for the National Background Check Program (NBCP) for any States or U.S. Territories that were unable to meet the previous deadline for submitting their applications under the previous solicitation. Applications will be due on October 30, 2012. Nursing Homes
12-41-ESRD Pilot Surveys Begin for the Survey & Certification (S&C) Quality Assurance Efficiency & Effectiveness (QAEE) Initiative #1: The End Stage Renal Disease (ESRD) Core Survey Process The S&C QAEE Initiative #1, the ESRD Core Survey process began a three-month Pilot Test phase on July 1, 2012. Following the 11-State Pilot Test phase and subsequent updating of Core Survey Process and Materials, the ESRD Core Survey process will be implemented nationally in FY 2013. A sample of draft Core Survey materials are attached. ESRD
12-42-NH Request to Convey Information: Partnership to Improve Dementia Care in Nursing Homes The memo was revised on August 31, 2012 to include additional stakeholders. CMS launched the Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for nursing home residents with dementia-related behaviors. Stakeholders are sending letters to support the Partnership to Improve Dementia Care in Nursing Homes. Nursing Homes

 

Publication Contact: Gina Bertolini
E-Mail: Gina.Bertolini@dhs.wisconsin.gov
Phone:  (608) 266-6691

MAIL SUBSCRIPTION SERVICES

http://www.dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM

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Last Revised:  August 25, 2014