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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/
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Memo No. |
Title |
Summary |
Providers Affected |
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12-008
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Heat Awareness
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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.
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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
|
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12-009
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MDS Section Q Referral to Local Contact Agency Process Program
Update
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This memo describes changes made to the MDS Section Q referral
process and revisions to the MDS 3.0 Section Q Referral form.
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Nursing Homes
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12-010
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Summary Survey Report - Due September 20, 2012
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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.
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Hospitals
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12-011
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E-SOD/e-POC Initiative, Provider Search Application, and Online
Posting of SODs and POCs
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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.
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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
|
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12-012
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Authentication of Physician Orders in Hospitals
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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.
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Hospitals
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12-013
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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.
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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
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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:
February 08, 2013
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