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DQA Quarterly Information Update

January 2009

PDF Version of this month's Quarterly Update (PDF, 138 KB)





Assisted Living Reaches Historic Milestone

November 19 was an historic day for Assisted Living. On that day, a registration was issued to a 111-bed RCAC and---for the first time---Assisted Living beds (CBRFs, RCACs, AFHs) surpassed nursing homes and FDDs by 96 beds. Assisted Living had 2,853 licensed, certified, and registered facilities and 38,775 beds compared to NH/FDD with 417 licensed facilities and 38,679 beds.

Looking back to 1981 when the Nursing Home Moratorium was instituted, there were approximately 600 NH/FDDs with a capacity of approximately 65,000 beds and approximately 600 CBRFs with approximately 6,000 beds. Twenty-seven years later, there are approximately 6,500 more beds (when adding AL and NH/FDD together); however, there has been a seismic shift regarding where people live.

assisted living chart

This shift is indicative of the overall health and strength of the assisted living industry and the hard work and dedication that has resulted as the AL community continues the important work of improving the lives of some of Wisconsin's most vulnerable citizens.

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All Provider Update: Refrigerator Monitoring When Storing Pharmaceuticals

Many facilities regulated by the Division of Quality Assurance will have refrigerators of all types that store medications. Some of the medications must be maintained at specific temperatures and can only be exposed to room temperatures for short periods of time. If the medications are exposed to room temperatures for too long the medication may no longer be effective. For instance, many vaccines can only be exposed to room temperature for a few hours. In the last year there have been reports across the country of various vaccines that have been exposed to inappropriate temperatures leading to re-immunization efforts for thousands of patients.

Providers should review the contents of the medication refrigerator and develop a procedure for refrigerator monitoring to protect the efficacy of the medications being stored. Refrigerator temperatures need to be monitored more often than once a week and may even require daily checks. Thermometers that continuously monitor temperature and assure that vital vaccines are maintained appropriately can usually be purchased for less than $100.

If you have questions about pharmaceutical refrigerator monitoring, please contact:

Doug Englebert

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Emergency Response Education

The State Expert Panel on Long-Term Care Facilities, in collaboration with the Hospital Preparedness Program of the Wisconsin Division of Public Health and Lakeshore Technical College, is offering facilities and their staff unlimited access to a Certificate Course in "Emergency Response for Healthcare - Basic Level."

Information about the course---course content, subscription fees, CDs, subscription form, and contact information---can be found at

If you have questions regarding this course or the subscription process, contact Rich Hoerth, Dean of Public Safety at 920-693-1237 or Lynn Senovich at 920-693-1106.

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Improved Communication with Non-Long Term Care Providers

Hospitals, Home Health Agencies, Hospices, ESRDs, Rural Health Clinics, Outpatient Rehabilitation Facilities, ASCs, CORFs

Effective with 2009 surveys, the Bureau of Health Services will offer an improved method of documenting the results of a verification visit. DQA will no longer mail a letter or copies of the computer generated CMS 2567B form following our visit. If a provider wants paper documentation of the outcome of the verification visit, they can e-mail the Bureau and request a provider profile report. The Bureau will answer the e-mail with an attached file containing the profile, which reflects all surveys and their status. To submit your request, contact Sandy Jencen at

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MDS and OASIS Recipient Medicaid Numbers

All Medicaid beneficiaries enrolled in Wisconsin Medicaid will soon receive a ForwardHealth Card with a newly-assigned 10-digit member identification number. This randomly-assigned "member number" replaces the previous 10-digit number based on an individual's Social Security Number and will provide greater security for Medicaid beneficiaries' identities and their protected health information.

Nursing homes and home health agencies should enter these new member numbers for their Medicaid clients at the time their next MDS or OASIS assessment is completed. When these records are submitted to the State MDS/OASIS System the Final Validation report will list warning message - 81, indicating that resident/patient information has been updated. Providers should verify that the number that follows "New" is the correct member number for this person.

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MDS and OASIS Broadband Connection Required

All nursing homes and home health agencies must use a broadband (cable/dsl) connection for MDS and OASIS assessment submissions. On February 1, 2009, CMS will discontinue access through dial-up.

Updated information, including a new broadband solution for providers that were having difficulty converting to broadband, has been posted at

Select the MDCN Information link in the blue outlined box on the right hand side of the page. The AT&T Global Client software version 7.2.1 and detailed set up instructions are available.

If you are using a network, a revised network document is available for download. Please forward this information to your network administrators. They will need the port information to ensure a successful connection.

Please do not wait until the last minute to set up your broadband connection. Technical support for your efforts is available at

MDCN Help Desk
800-905-2069 (Choose option 2 for technical support.)

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New Revision of OASIS-C

CMS released the newest revision of OASIS-C for Home Health agencies on November 14, 2008. OASIS-C is expected to replace the current version of OASIS, effective January 1, 2010. Field testing of the instrument is complete, and CMS is publishing OASIS-C for the 'final public comment' period, ending 1/13/09. This new revision, dated 11-11-08, can be viewed at Information related to submitting comments to CMS is available in the Federal Register article published November 14, 2008, and is available at

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Office of Caregiver Quality (OCQ) Updates

Receiving Results of the Nurse Aide Examination

Nurse aide candidates receive the results of their National Nurse Aide Assessment Program (NNAAP) examination by one of two methods---via fax or mail. The quickest and most common way to receive these results is via fax at the test site shortly after the evaluator has faxed the completed examination score sheet to Pearson Vue. Should the candidate not want to wait for the faxback results, the results will be mailed to the candidate from Pearson Vue.

If the fax system is not working, the score sheets must be hand scored at Pearson Vue in Philadelphia. The evaluator sends all the score sheets to Pearson Vue via FedEx the next business day after the test date. Pearson Vue has ten business days from the day Pearson Vue receives the score sheets to hand score them and mail the results out to the candidate. Test results can not be given over the telephone.

After the test is hand scored, the results (fail or pass) are mailed out to the candidate at the address listed on the candidate's test application. Note: It takes about four or five days for mail correspondence to get from Philadelphia to Wisconsin.

  • If the candidate passes the examination, the candidate is placed on the Wisconsin Nurse Aide Registry and a Registry card is mailed to the candidate.
  • If the candidate fails the examination, the score report provides the candidate with the information needed to reapply and to take the part or parts of the exam that have been failed.

The nurse aide candidate should contact Pearson Vue at 1-877-329-8760 if their name does not appear on the Wisconsin Nurse Aide Registry within 15 business days after having taken the NNAAP examination or if they have not received their test results after 20 business days. The candidate must provide Pearson Vue with the information that will assist Pearson Vue with its research---test site, test date, and the name of the evaluator, if possible. For more information, see the Wisconsin Nurse Aide Candidate Handbook at

DQA Regulated Entity Background Check Process

If an entity wishes their license approval to continue, the license holder or legal representative must submit the completed forms for the required four-year renewal process regardless of when a DQA regulated entity last submitted an application for licensure, certification, or registration,

Some license holders/legal representatives have still not complied with the requirements as stated in DQA Memo 08-015. If you have not submitted the necessary paperwork, access the Department's web page at:

to obtain the necessary forms for the Existing License Holder Four-Year Renewal Background Check Process. Providers who have failed to comply will be cited in 2009.

If you have questions regarding this matter, contact

DQA Office of Caregiver Quality
(608) 261-8319 Telephone
(608) 264-6340 FAX

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Changes in DQA Staff

Mary Eckwright, Nurse Consultant, Joins BAL WRO Survey Team

Mary Eckwright, Nurse Consultant, will be joining the Bureau of Assisted Living's Western Regional Office survey team on January 4, 2009. Mary is transferring from the Bureau of Nursing Home Resident Care, where she has been a nursing home surveyor for five years. Mary is a registered nurse with a bachelor's degree from the University of Wisconsin in Eau Claire. She previously worked at Northern Wisconsin Center as a QMRP and as a nursing supervisor and at Lutheran Social Services in the development of group homes and the supervision of their personal care worker program.

Tracy Moraine, Medical Technologist, Joins CLIA

The Division of Quality Assurance welcomes its new CLIA surveyor, Tracy Moraine. Tracy has a Bachelor of Science degree in Medical Technology with over 25 years of experience as a Medical Technologist. Tracy has worked in various hospitals, clinics, and independent laboratories in the role of manager, Medical Technologist, coordinator, and supervisor. Tracy was also an instructor at UW-Milwaukee.

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DQA Numbered Memos (October, November, December)

Access these memos via:

or via individual providers' publications pages at

DQA Memos

Memo No.



Providers Affected

08-025 Guidelines for Managing (Methicillin-Resistant Staphylococcus Aureus) MRSA This memo provides guidance for managing MRSA when present in residents of assisted living facilities and will specifically address MRSA as the most commonly encountered multidrug-resistant organism in assisted living facilities. Adult Family Homes
Community-Based Residential Facilities
Residential Care Apartment Complexes


08-026 08-026 - Changes to Wisconsin Administrative Code Chapter HFS 129 - OBSOLETE 9/13 This memo provides feeding assistant, medication aide, and nurse aide training programs with information on the changes to Chapter HFS 129 and notifies them of the June 30, 2009 implementation deadline. Medication Aide Training Programs
Nurse Aide Training Programs
Nursing Homes
08-027 08-027 - Change in the Statement of Deficiency (SOD) Numbering System - OBSOLETE 9/13 DQA has recently implemented a new database, the ASPEN Licensing Information System (ALIS), to replace its former Facility Licensing and Certification Information System (FL/CIS).  This memo serves as notification and explanation of the change in the SOD numbering system effective January 1, 2009. Facilities for the Developmentally Disabled
Home Health Agencies
Nurse Aide Training Programs
Nursing Homes
Rural Health Clinics
Certified Mental Health and AODA
Ambulatory Surgery Centers
End Stage Renal Dialysis Units
Outpatient Rehabilitation Facilities
08-028 Wisconsin Administrative Code Chapter HFS 131 Variances This memo addresses three areas of Wisconsin Administrative Code Chapter HFS 131 that require variances in order to be consistent with the Federal Conditions of Participation (CoP) for Hospices Hospices
08-029 Revisions to Wisconsin State Statutes, Chapter 50, and Chapter HFS 12, Wisconsin Administrative Code Wisconsin Act 172 was signed into law on March 26, 2008.  Newly created section 50.065 (2m), effective November 1, 2008, requires entities to disclose certain information regarding a caregiver who is assigned to provide personal care services in a client's residence.

The new law also requires DHS to specify, by rule, crimes for which an entity must disclose a conviction of its caregivers who are assigned to provide personal care services.

Home Health Agencies
08-030 08-030 - Implementation of Wisconsin Administrative Code DHS 129 - OBSOLETE 9/13 DQA Memo 08-026 announced the legislature's approval of the revisions to Chapter DHS 129.  The purpose of this memo is to provide direction and guidance regarding the actual implementation of the changes that affect the training of nurse aides as of December 1, 2008. Nurse Aide Training Programs

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HFS Administrative Rules Update

HFS 12 - Caregiver Background Checks

On September 15, 2008, the Wisconsin Administrative Rules website published the Initial Proposed Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code, Chapter HFS 12. Section 50.065 (2m) (d) requires the Department to promulgate rules to specify crimes for which an entity must disclose to a client or the client's guardian, a conviction of a caregiver who is assigned to provide personal care services to the client in the client's personal residence and to specify who is a "substitute caregiver." The proposed rule was revised based upon comments received from advocacy organizations, trade and professional associations, and other interested parties.

A public hearing for the rule was held on January 6, 2009 in Madison. Written comments regarding the proposed rule will be accepted until January 13, 2009.

For more information, you may view the proposed rule and public hearing notice on the Wisconsin Administrative Rules website at

HFS 83 - Community Based Residential Facilities

On November 25, 2008, the Wisconsin Administrative Rules website published the Final Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code, Chapter HFS 83. The goal of the proposed rule is to focus on resident outcomes and quality of life and quality of care, improve readability and organization, eliminate excess and prescriptive language, revise staff training standards establishing a more cost effective system for providers, and promote the use of nationally recognized standards of practice.

The rule is expected to become effective April 1, 2009. For more information, you may view the final rule on the Wisconsin Administrative Rules website at

HFS 85 - Non-Profit Corporation as Guardian

On September 19, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter HFS 85, Non-profit Corporation as Guardian. Through this initiative, the Department proposes to make the rule reflect current standards of practice, recognizing the increase in the number of adults in need of guardianship and the increase in the complexity of their needs.

An Advisory Committee, including advocates, providers, registers in probate, and County adult protective services staff met and reviewed proposed rule language and made recommendations for change. The Department revised the proposed rule based upon comments from the Advisory Committee. The proposed Rule Order is currently under review by the DHS Office of Legal Counsel. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at

HFS 124 - Hospitals

On April 1, 2005, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter 124. The Department is planning to update Chapter HFS 124 to eliminate overly prescriptive and outdated regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements.

The Department asked representatives from a large number of trade and professional associations, hospitals, and other interested parties, to review proposed revisions to the rule and make recommendations for change. The Department is reviewing their recommendations and preparing a revised draft of ch. HFS 124 for further review by stakeholders. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at

DHS 129 - Certification Programs for Training and Testing Nurse Aides, Home Health Aides, and Hospice Aides

On December 1, 2008, revisions to Chapter DHS 129 went into effect. The revised rule includes training and testing requirements of feeding assistants and medications aides, reflects the standardization of the administration and operation of nurse aide competency evaluation by a contracted agency, improves the accuracy and integrity of the nurse aide registry, and expands the mechanisms available for enforcing compliance of training and testing programs. For more information, you may view the rule at

DQA Memos 08-026 and 08-030 provide important information about the implementation of the revised rule and can be found at

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CMS Survey & Certification Letters (October, November, December)

Listed below are Survey and Certification (S&C) Letters distributed by CMS during the last quarter. Please note that the CMS Internet site where you can review all S&C memos is

Survey and Certification Letters

S&C No.



Providers Affected

09-01 Advance Copy ESRD Program Interpretive Guidance Version 1.1 This memo includes an advance copy of the ESRD Interpretive Guidance End Stage Renal Dialysis Units
09-02 Approval of Deeming Authority of Det Norske Veritas Healthcare, Inc. for Hospitals  This memorandum announces the CMS decision to approve Det Norske Veritas Healthcare, Inc. (DNV Healthcare) for recognition as a national accreditation program for hospitals seeking to participate in the Medicare program. Hospitals
09-03  Enforcement of Section 506, MMA, Acceptance of Medicare-like Rates Section 506 of the MMA requires hospitals and critical access hospitals (CAHs) to accept Medicare-like rates when providing care to individuals who are beneficiaries of Indian Health Service (IHS), Tribal health, and urban Indian health programs. 42 CFR 489.29 implements the statutory requirement. Hospitals
Critical Access Hospitals
09-04 Adoption of New Fire Safety Requirements for LTC, Mandatory Sprinkler Installation Requirement The purpose of this memorandum is to notify States and regional offices of the publication on August 13, 2008, in the Federal Register (73 FR 47075), of a final rule entitled, "Medicare and Medicaid Programs; Fire Safety Requirements for Long Term Care Facilities, Automatic Sprinkler Systems," with an effective date of October 14, 2008. Long Term Care Facilities
09-05 Special Focus Facility (SFF) Program Survey Scoring Methodology  This memorandum provides specific details on the scoring methodology used to identify those nursing homes that become candidates for the SFF initiative by virtue of their more serious history of severe and persistent quality of care problems. We explain the method for scoring nursing home deficiency findings and survey results. The SFF methodology produces a score for identifying those facilities that merit closer survey attention through the SFF initiative. Nursing Homes
09-06 Revised CLIA Policy on Quality Control for Commercially Available Microbial Identification Systems This memorandum revises the analytic system information for microbial information systems found in CMS Interpretive Guidelines (IG) for Laboratories and Laboratory Surveyors.  CLIA Certified Laboratories 
09-07 New Web Feature: Laboratories Demographic Look-Up This letter announces the introduction of the CLIA Laboratory Demographics Look-up link on the CMS CLIA Web site. The CLIA Laboratories Demographic Look-up link leads to demographic information about CLIA certified laboratories. CLIA Certified Laboratories
09-08 Accreditation and its Impact on Various Survey and Certification Scenarios  CMS has developed a comprehensive set of FAQs and responses related to the impact of a provider / supplier's accreditation status on various survey and certification activities. Although much of this guidance may be found in various sections of the SOM or in previous S&C policy memoranda, the FAQs make this information available in one document.  All Accredited Providers / Suppliers 
09-09 Advance Copy - Organ Transplant Program State Operations Manual (SOM) and Survey Protocol Included in the memo is an advance copy of changes to Chapters 2 and 3 of the SOM and the Survey Protocol which will be included in Appendix X of the SOM. Organ Transplant Programs
09-10 Standing Orders in Hospitals Revisions to S&C Memoranda CMS is clarifying a portion of S&C-08-12 and S&C-08-18, issued on February 8 and April 11, 2008 respectively, regarding use of standing orders in hospitals. Hospitals
09-11 Release of Report - Freedom from Unnecessary Physical Restraints: Two Decades of National Progress This report evaluates the efforts to reduce the use of physical restraints after Congressional Passage of the 1987 Nursing Home Reform Act. Nursing Homes
09-12 SOM Chapter 5 Update - Release of Person-Identifiable Data Related to Restraint/Seclusion Deaths S&C-08-23, issued May 30, 2008, updated Section 5140 of the SOM, concerning handling of hospital reports of deaths associated with the use of restraint or seclusion. Hospitals
09-13 Waivers and Phase-In Time Extensions for the Implementation of the New ESRD Conditions for Coverage While the overall effective date for implementing new or revised ESRD Conditions for Coverage was October 14, 2008, the rule specifies separate effective dates for certain Conditions and provides that some facilities may request a waiver for certain other requirements. In this memorandum we describe the procedures CMS is implementing for requesting a waiver or time-limited extension of the time needed to phase-in the program improvements needed to achieve full compliance. End-Stage Renal Dialysis Units
09-14 Interim Guidance Regarding the Survey and Certification of RHCs and FQHCs  The regulations at 42 CFR Part 405, Subpart X, Section 2401 and 42 CFR Part 491, Subpart A, governing RHC and FQHC participation in Medicare, have undergone major changes in recent years and are now proposed for further changes. This memorandum provides an overview of previous changes and clarifies the current RHC and FQHC regulatory requirements. Rural Health Clinics
Federally Qualified Health Centers
09-15 New CAH requirements under 42 CFR 485.610(e) related to CAH Co-location and provider-based locations CMS published a final rule in the November 27, 2007 Federal Register (72 Fed. Reg. 66934) amending 42 CFR Part 485 Subpart F, adding a new standard at 485.610(e), governing a CAH's location relative to other hospitals or CAHs with respect to co-location and off-campus provider-based arrangements. These amendments became effective January 1, 2008 Critical Access Hospitals
09-16  Additional Revision of SOM - Federally Qualified Health Centers (FQHCs) Sections 2003A and 2826 of the SOM are being revised to clarify the effective date for FQHC supplier agreements and to update information on the Medicare Administrative Contractor (MAC) and legacy Fiscal Intermediary (FI) assignments for tribal and Urban Indian FQHCs. Federally Qualified Health Centers
09-17 Launching of Five Star Rating System on the Nursing Home Compare Website The purpose of this memorandum is to give the State Survey Agencies advance notice of the Five Star Quality Rating System being added to the Nursing Home Compare Web site. States will receive a preview of their provider's Five-Star rating on December 15, 2008. Providers will have access to their individual Five-Star rating beginning December 16, 2008. Nursing Homes
09-18 The Five Star Nursing Home Rating System -Questions and Answers The Five Star Nursing Home Rating System was launched on December 18, 2008, to give consumers a more user friendly way to compare nursing homes within a State. This memo provides a comprehensive set of questions and answers concerning the Five Star Rating System. Nursing Homes


Content contact: Gina Bertolini
Phone: (608) 266-6691


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Last Updated: March 31, 2014