DQA Quarterly
Information Update
April 2011
PDF Version of this month's Quarterly Update
(PDF, 127 KB)
NEW THIS ISSUE
REGULAR FEATURES
UPCOMING EVENTS
NEW THIS ISSUE
Update on DQA's Annual FOCUS Conference
Bureau of Technology, Licensing an Education
The Department of Health Services has determined that
planning for the annual joint provider/surveyor conference should be
turned over to a non-state entity. Therefore, DQA will not be proceeding
with plans for a conference in 2011. Your support and attendance at previous
conferences has been greatly appreciated.
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OASIS Updates
Bureau of Technology, Licensing and Education
OASIS-C Guidance Manual and Errata Sheets
CMS released the third OASIS 'errata sheet' dated December 2010, which
contains a listing of changes incorporated into the December 2010 revision
of the OASIS-C Guidance Manual. The errata sheet lists all the revisions
included in the 12/2010 version of the Guidance Manual for your convenience,
as well as other refinements and clarifications on data collection. Both the
errata sheet and the guidance manual were originally posted by CMS on
January 5, 2011 but, due to a significant typographical error, both were
reposted on January 13, 2011. Make certain that you have the latter version.
The errata sheet and revised Guidance Manual can be obtained by scrolling to
the bottom of this webpage:
http://www.cms.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp
You will see a "zip file" dated January 2011. However, when you
download the manual, the pages are actually dated December 2010.
CMS plans to republish the entire Guidance Manual (on-line) only once per
year, but will publish errata sheets several times per year that summarize
changes/corrections to the Guidance Manual as they occur. The errata
revisions are effective immediately upon publication and will be
incorporated into the next republication of the entire Manual.
New Quarterly OASIS Q&As and Revised Q&As
In January 2011, the newest quarterly OASIS Q&As were released by
the Centers for Medicare and Medicaid (CMS) and the OASIS Certificate and
Competency Board (OCCB). These two groups collaborate to release new
Q&As each quarter. The next release is scheduled for April 21st.
Q&As that are directly related to OASIS-C items begin with the October
2009 set.
The quarterly Q&A sets are posted to the OCCB website, which was
revised a few months ago and has a whole new look. The overhauled website
may be difficult to maneuver initially, but you can get to the Q&As by
going to the "Resources" tab at the top right of the home page:
www.oasiscertificate.org
CMS has also begun revising the long list of OASIS Q&As that have
been published since the inception of OASIS. CMS had previously published
the Q&As grouped into twelve categories of similar/like items; e.g.,
OASIS Applicability, Comprehensive Assessment, Dataset Items, etc. They have
now started revising these Q&A categories, making each answer
appropriate for the current OASIS-C dataset. The first four categories were
revised and posted in January. To obtain the revised Q&A's, go to this
webpage and select categories 1- 4, dated 1/10/11: https://www.qtso.com/hhafaq.html
Casper Reports
CMS updated the CASPER User's Manual; the manual walks you through using
the CASPER system to obtain/read your HHA's reports derived from OASIS data.
Chapter 2 is particularly useful for understanding the details of how to
obtain your HHA's reports; this chapter was updated in February 2011. The
revised manual is available for download on the state's OASIS Welcome page,
which is the same website utilized for transmitting OASIS data to the state.
The CASPER system support staff discovered that the "Tally
Report" has a limitation: you cannot obtain a report that covers a time
period containing more than 5,000 patient episodes of care. So, it's a
matter of the "report size" that's at issue. If you experience
problems obtaining a "Tally Agency Patient-Characteristics Report"
or receive a warning message that the report is over 5,000 episodes, change
your "date parameters" to a smaller time frame in order to obtain
a report with fewer episodes.
CMS has released a new transition timeline defining the projected
availability of OASIS-C Casper reports. As you may recall, not all of the
OASIS-C reports were going to be available at the same time; different
reports were being made available (transitioned) as sufficient information
was gathered to create reliable reports. CMS projects that all of the Casper
reports should be available by May/June of this year. To see the new
transition timeline, scroll to the "downloads" section of this
webpage: http://www.cms.gov/HomeHealthQualityInits/10_HHQIQualityMeasures.asp
CMS-Sponsored OASIS Video Training
CMS released four web-based YouTube trainings for OASIS, as promised. The
first release was "Understanding PBQI" (Process-based Quality
Improvement). Later, three additional videos were released that targeted
specific M-questions: M1910, M2250, and M2400. You can find these training
videos here:
NOTE: If these links do not work for you, go to the YouTube
website and do a search for "CMS+OASIS;" all four selections
should appear (along with other items) as a result of your search.
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New DQA Construction Listserv Available for
Subscription
Office of Plan Review and Inspection
The Division of Quality Assurance is pleased to announce that a new
listserv (e-mail distribution list) is now open for subscription on the
Division's website. This listserv, called "DQA Construction," will provide
subscribers with notice of DQA physical plant memos, CMS Life Safety program
letters, questions and answers, and interpretations. Subscribers to the
listserv will receive e-mail messages announcing the availability of such
publications along with links to the actual memos and letters.
To subscribe to the DQA Construction listserv, go to the Division's
E-Mail Subscription Service webpage at: http://www.dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM
You will need to enter the e-mail address at which you wish to receive
listserv messages. Upon submitting your subscription request, you will
receive an e-mail (at the address you supplied) asking you to confirm your
subscription. After doing so, you will receive confirmation. Details on the
subscription process for this and other DQA listservs are on the Division
website.
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Effect of Change from AT&T to Verizon on Nursing
Homes and Home Health Agencies
Bureau of Technology, Licensing and Education
CMS is changing vendors for connecting nursing homes and home health
agencies to the QIES MDS and OASIS Systems. AT&T is the current vendor,
but CMS hopes to transition to Verizon by June 30, 2011. Providers currently
have to install and use the AT&T Global Client software to connect to
the QIES MDS and OASIS Systems to submit records. Verizon will be providing
a clientless web-based access solution that does not require installing
software. CMS will be releasing additional information in the coming months.
Providers should watch for alert messages on the MDS and OASIS welcomes
pages and also periodically check for information on the QIES Technical
Support Office website at:
https://www.qtso.com/
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MDS News
Bureau of Technology, Licensing and Education
Change in MDS Correction Policy
Effective with submissions on April 1, 2011, CMS will no longer allow
facilities to modify the MDS 3.0 reason for assessment items, assessment
reference date (ARD), discharge date, and entry date. If a modification
record is submitted attempting to change any of these items, the record will
be rejected. These MDS items must be corrected by inactivating the old
record and submitting a new record. Chapter 5 of the RAI manual will be
revised to reflect this change.
Only OBRA and Medicare PPS Assessments Allowed to be Submitted
On the January, 2011, SNF Open Door Forum conference call, CMS explained
only MDS 3.0 assessments that are OBRA assessments or Medicare Part A PPS
assessments should be submitted to the QIES ASAP MDS System. Assessments
completed for Medicare Advantage Plans or for other insurance purposes
should not be submitted. CMS acknowledged this is a change from MDS 2.0,
which allowed submission of all MDS assessments.
MDS 3.0 Training Videos
March 1, 2011, CMS posted the following three additional MDS 3.0 training
videos on YouTube:
- Section M: Skin Conditions
- Evening Experts Panel Discussion
- Dr. Deb Saliba's Introduction
Links to these videos and other MDS 3.0 training videos are available on
the following CMS MDS 3.0 Training Materials web page: http://www.cms.gov/NursingHomeQualityInits/
45_NHQIMDS30TrainingMaterials.asp
Nursing Home Five-Star Quality Rating System
CMS created a Five-Star Quality Rating System to help consumers, their
families, and caregivers to compare nursing homes. The Nursing Home Compare
website provides a quality rating system that gives each nursing home a
rating of between 1 and 5 stars. Nursing homes with 5 stars are considered
to be of a quality much above average; nursing homes with 1 star are
considered to be much below.
The Five-Star Quality Rating System is based on facility performance in the
areas of survey inspection results, staffing information, and quality
measures. Starting in April, 2011, the quality measures domain will not be
included in the calculation of the 5-Star Quality Rating and only the
domains of inspections and staffing will be used. The MDS 3.0 quality
measures are not expected to be available until 2012, at which time they
will be added back into the calculation. The CMS Nursing Home Compare
website is located at: http://www.medicare.gov/NHCompare/home.asp
MDS 3.0 Automation Nursing Home Training
The Division of Quality Assurance will be presenting a training
opportunity for nursing home staff who are involved with the transmission of
MDS 3.0 assessment records to the CMS QIES MDS System. This program will be
held on May 24, 2011, at the Holiday Inn - Convention Center in Stevens
Point.
This training program will review the process required for nursing homes to
connect to the CMS QIES ASAP MDS System and the Certification and Survey
Provider Enhanced Reporting (CASPER) System to transmit MDS records,
retrieve validation reports, and access other MDS related reports.
Training brochures, including registration information, have been mailed to
all nursing homes. The training brochure and online registration are
available on the Division of Quality Assurance online educational
opportunity information website at: http://www.dhs.wisconsin.gov/rl_DSL/Training/index.htm
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REGULAR FEATURES
Changes in DQA Staff
Claudette Bradley, RN
Nurse Consultant / Bureau of Health Services
Great News! We have filled the vacant Nurse Consultant position in
Milwaukee. Claudette Bradley will be surveying Hospitals and ESRDs.
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DQA Numbered Memos (January, February, March)
Access these memos via
http://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 |
| 11-001 |
Revisions to Chapters DHS 83 Community
Based Residential Facilities and DHS 88 Licensed Adult Family Homes -
Effective January 1, 2011
|
The DQA Omnibus Rule, amending provisions
in DHS 83 and DHS 88, takes effect 01/01/2011. Administrative rules
were amended to correct cross references, links, and charts, and to
make other minor changes.
|
Adult Family Homes, Community Based Residential Facilities
|
| 11-002 |
Office of Plan Review and Inspection
|
In July 2010, it was announced that the
Wisconsin Department of Administration had approved the DHS request to
reorganize the DQA. The reorganization created the Office of Plan
Review and Inspection (OPRI) and moved DQA's Civil Engineer Advanced
and support staff positions from the Bureaus of Health Services and
Nursing Home Resident Care to OPRI.
|
Ambulatory Surgery Centers, Community Based Residential Facilities,
End Stage Renal Dialysis Units, Hospices, Hospitals, Nursing Homes, Relationship Enhancement Committee,
Design Professionals
|
| 11-003 |
Carbon Monoxide Alarms New Requirements
Expand Coverage to Most Residential Buildings
Effective February 1, 2011
|
On February 1, 2011, new requirements in
2009 Wisconsin Act 158 and Chapters Comm 21 and 28, relating to Carbon
Monoxide Alarms, will go into effect.
|
Adult Family Homes, Community Based Residential Facilities,
Residential Care Apartment Complexes
|
| 11-004 |
Respiratory Therapy Orders in Hospitals
|
The purpose of this memo is to inform
hospitals regulated by the DQA about a statewide variance of DHS 124
related to respiratory therapy orders.
|
Hospitals
|
| 11-005 |
Listing of Mental Health Practitioners
Using Individual Provider Status Confirmation Letters
|
The DHS, DQA, Behavioral Health
Certification Section and the Bureau of Prevention, Treatment and
Recovery have participated in a series of meetings with the Joint
Board of Marriage and Family Therapy, Professional Counseling and
Social Work, and the Dept of Regulation and Licensing regarding
credentialing options for mental health practitioners currently
providing psychotherapy, following confirmation of their training and
clinical experience via the Individual Provider Status Application
process.
|
Certified Outpatient Mental Health Clinics
|
| 11-006 |
Employment Requirements for "Nurse
Technicians" and Student Nurses Working as Nurse Aides
|
This memo provides information regarding the
role and responsibilities of "nurse technicians," and
student nurses. This memo (1) clarifies that "nurse
technicians" are nurse aides and must comply with the training
and testing requirements for nurse aides who work in health care
facilities; (2) explains employment requirements for student nurses
who work as nurse aides in health care facilities; and (3) clarifies
charge nurse and staffing requirements.
|
Nurse Aide Training Programs, Nursing Homes
|
| 11-007 |
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.
|
Federally-certified Nursing Home
Administrators, ADRC Directors, Area Agencies on Aging Executive Directors,
Board on Aging and Long Term Care Executive Director, County DHS Directors,
County DSS Directors, County DCP Directors, County/Tribal Aging Unit Directors,
Disability Rights Wisconsin Executive Director, MCO CEOs
|
| 11-008 |
Notice of State Only Re-Visit Fee
|
Act 205 became effective 06/29/09 and
created new language for Nursing Homes authorizing a $200 fee for
onsite re-visits resulting from State administrative code violations.
This memorandum outlines the nursing home re-visit fee process that
DQA implemented on December 1, 2009.
|
Nursing Homes, Facilities for the Developmentally Disabled
|
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CMS Survey & Certification Letters (January,
February, March)
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.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
|
S&C No. |
Title |
Summary |
Providers Affected |
|
11-05-LSC
|
Hospital and Critical Access Hospital (CAH)
Facility Life Safety Code (LSC) Occupancy Classification
|
Hospital and CAH component facilities may be
classified as new or existing Health Care, Ambulatory Health Care,
Business, or other occupancies, as allowed by provisions of the LSC.
|
Hospitals, Critical Access Hospitals |
|
11-08-CLIA |
Clinical Laboratory Improvement Amendments of 1988 (CLIA) |
This memo provides guidance on the applicability of
CLIA regulations to testing associated with blood, cells/tissue, and
organs for transfusion, implantation, infusion, or transplantation. |
Clinical Laboratories |
|
11-09-AO-CAHs |
Approval of Deeming Authority of Det Norske Veritas
Healthcare (DNVHC) for Critical Access Hospitals |
CMS has approved DNVHC as a national accreditation
program for CAHs seeking to participate in the Medicare or Medicaid
programs. |
Critical Access Hospitals |
|
11-10-Hospitals |
Revised Hospital Anesthesia Services Interpretive
Guidelines - State Operations Manual Appendix |
Revisions to Recently Updated Interpretive Guidelines
for Anesthesia Services |
Hospitals |
|
11-11-HHA |
Revised Home Health Survey Protocols |
CMS is issuing revisions to the existing HHA survey
process. New State Operations Manual Appendix B is provided. |
Home Health Agencies |
|
11-12-NH |
Relationship Between Civil Money Penalty Funds Paid
by Nursing Homes and the Money Follows the Person Rebalancing (MFP)
Demonstration grant program. |
This letter explains the relationship between civil
money penalty funds collected from nursing homes that have been out of
compliance with Federal requirements and programs designed to provide
alternatives to nursing homes, such as the MFP Demonstration grant
program. |
Nursing Homes |
|
11-13-ESRD |
Update of End Stage Renal Disease (ESRD) |
CMS wants to promote common understanding about the
regulatory process and the specific rules that guide the CMS S&C
process in order to promote consistency of standards and expectations
regarding the ESRD CfCs, |
End State Renal Dialysis Centers |
|
11-14-ICF/MR |
Clarification of Self-Administration of Medications |
It has been the expectation of ICF/MR surveyors,
pursuant to previous CMS interpretations of 483.460(k)(4), that every
client residing in an ICF/MR must participate at some level in a
formal, self-administration program for medications. |
Intermediate Care Facilities for the Mentally
Retarded |
|
11-15-ICF/MR |
Clarification of Reporting Mistreatment, Neglect,
Abuse, and Injuries of Unknown Source |
Both State and Federal surveyors have requested
further clarification regarding the parameters surrounding what
constitutes "injuries of unknown source," the definition of
"immediate," and to whom such allegations/injuries must be
reported. |
Intermediate Care Facilities for the Mentally
Retarded |
|
11-16-NH |
Publication of Final Rule Civil Money Penalties for
Nursing Homes |
The final rule "Civil Money Penalties for
Nursing Homes," was published in the Federal Register on March
18, 2011. |
Nursing Homes |
|
11-17-NH |
April and July 2011 Changes to Nursing Home Compare |
This memo describes changes that CMS will make to the
Nursing Home Compare website on April 23, 2011 and on July 21, 2011.
CMS is soliciting comments about these website changes. CMS will be
evaluating the website in a systematic way, including seeking comments
from stakeholders and visitors to the site. |
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 Updated:
June 18, 2013
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