Department of Health Services Logo


Wisconsin Department of Health Services

If You Have Complaints about Wisconsin Health Care

Information about Division of Quality Assurance (DQA)

Provider Types Regulated by DQA

DQA Listservs

Provider Search

Provider Training

DQA Numbered Memos

DHS Forms

Remodeling of Health Care Facilities

WI Nurse Aide Training and Registry Info

Caregiver Program/ Background Checks

WI Adult Programs Caregiver Misconduct Registry

DQA Quarterly
Information Update

April 2012

PDF Version of this month's Quarterly Update (PDF, 132 KB)





Hospice: Scope and Frequency of Services
Bureau of Technology, Licensing and Education

"Is a signed physician order needed?"

The question of whether or not a signed physician order is required when there is a change in visit frequency has been asked a few times recently. Neither the State nor Federal regulations for Hospice services specifically identify that a signed physician order is needed.

Wisconsin Administrative Code DHS 131.21(3)(b) 2 states that the plan of care shall include "a detailed statement of the scope and frequency necessary to meet the specific patient and family needs."

The Federal Regulation that addresses this can be found in the State Operations Manual at 418.56(c)(2): A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

The Interpretive Guidelines for 418.56(c)(2) state that the use of visit ranges in the patient plan of care should follow these parameters:

  • The plan of care (POC) may include a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient.
  • A range of visits is acceptable as long as it continues to meet the identified needs of the patient/family.
  • Visit ranges with small intervals are acceptable (i.e., 1-3 visits/week; 2-4 visits/week) but ranges that include "0" as a frequency are not allowed.
  • The Interdisciplinary Group (IDG) may exceed the number of visits in the range to address patient/family's needs. There should be documentation in the record to support the need for the extra visit(s).
  • If the patient requires frequent use of PRN visits, the plan of care should be updated to include the need for additional visits.
  • Standing orders or routine orders must be individualized to address the specific patient's needs and signed by the patient's physician.
  • The IDG should be proactive in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis.

CMS has provided the following clarification on this issue:

All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This plan of care must also include a detailed statement of the scope and frequency of services needed to meet the specific patient and family needs.

CMS recognizes the importance of the IDG's assessment of an individual patient, and requires hospices to update the comprehensive assessment as frequently as the condition of the patient requires. The hospice IDG should then identify when a change is needed to the plan of care in order to meet the patient's identified needs.

CMS recognizes that the need for additional visits may occur with a hospice patient and the interpretive guidelines allow for the use of PRN orders for visit frequencies to ensure that the most appropriate level of service is provided to address the patient/family's needs. CMS does not regulate how PRN orders for visit frequency should be written. Reasons for PRN visits could vary considerably and it would be difficult to state the reason for every PRN visit before it occurs. Reasons for the PRN visits, when they occur, should be documented in the clinical note for that visit and must be conducted in accordance with accepted professional standards of practice, and in compliance with the hospice conditions of participation and any other Federal, State or local law.

The synergy of assessments, IDG approach and plans of care should reflect the needs of the patient and how those needs are being addressed.

It is important to stress that this response only applies to the question of visit frequency. Signed physician orders are required under any other circumstance as dictated by Standards of Practice, State or Federal regulations, e.g., medication orders. Some other payer sources, e.g., private health care insurance with a hospice benefit, may require physician signed orders for visit frequency.

It is also critical that documentation clearly reflect the change in the POC based on the IDG assessment of need and collaboration with attending physician.

If you have any questions or need further clarification contact:

Trudy Ciszek, RN

Back to top

Ann Hansen: WWIG Scholarship Recipient
Bureau of Health Services

Twenty-three women working in and with state and local government have received full scholarships to participate in the 12th Annual Public Policy Graduate Seminar program, Wisconsin Women in Government (WWIG). The six-week course, offered in cooperation with the La Follette Institute of Public Affairs at UW-Madison, ran from January to February. Ann Hansen, a QAPS-Senior in the Bureau of Health Services (BHS), is a recipient of one of the scholarships.

Scholarship recipients take part in this management and leadership training which is specifically tailored for those who either work in state government or who interact with state government as part of their jobs in the private sector.

The Graduate Seminar is a program fully funded by Wisconsin Women in Government (WWIG) and offered in cooperation with the La Follette School of Public Affairs. It is funded through an annual banquet fundraiser, held every spring, and attended by 1,000 state and local elected officials, business leaders, public servants, and political enthusiasts.

Back to top

Administrator's Office

Since January, the following counties have established ADRCs: Adams, Kewaunee, Marinette, Menominee, Oconto, Oneida, Shawano, Taylor, and Vilas.

Back to top

Office of Caregiver Quality

Transferring a nurse aide status from another state's Nurse Aide Registry to the Wisconsin Nurse Aide Registry?

Only nurse aides who have completed a training program of 120 hours or more that includes a minimum of 32 hours of clinical training are eligible to transfer to Wisconsin's Nurse Aide Registry. You may access the Registry Out-of-State Application form via:

To complete this process, the transferring aide completes Part I of the Registry Out-Of-State Application and attaches verification of their personal identity, including:

  • Name
  • Date of Birth
  • Social Security Number
  • A copy of their training certificate of completion or official transcript indicating completion of at least 120 hours of training with 32 hours of clinical.

The completed form is then mailed to the Nurse Aide Registry in the state where the nurse aide is currently listed. You can find the address and phone number of each state's nurse aide registry via:

Nurse aide registry personnel in that state will complete Part II of the application, verifying the individual's status in that state. The other state will then mail the completed application to Wisconsin. Wisconsin registry staff will then process the out-of-state application and the applicant will be notified by mail whether they were or were not placed on the Wisconsin Registry.

PLEASE NOTE:  Nurse aides transferring from another state may not provide "hands on" care in a facility in Wisconsin until they have been placed on the Wisconsin Nurse Aide Registry. The provision in 146.40(2)(c) which allows an individual to be employed as a nurse aide for fewer than 120 calendar days does not apply to individuals who are already listed on another state's registry and wish to transfer to Wisconsin.

Back to top

DQA Implements New Provider Search Application
Bureau of Technology, Licensing and Education

The Division of Quality Assurance is pleased to announce a new online Provider Search application that is scheduled to be implemented in April, 2012. This application supplements the provider directories that DQA has posted on its website for several years and will give users the ability to create lists of providers that meet their specific needs.

This Internet-based application will include all provider types regulated by DQA and will allow consumers to locate providers they are interested in by entering geographic and other search criteria. Users may identify specific types of health care providers, a provider's name, a specific county, city, zip code, or distance from a zip code. Users interested in assisted living facilities can also search for providers licensed to serve specific client groups. All providers matching a user's search criteria will display in a list, along with a Google map identifying their location. Users may then select a specific provider and obtain additional information, including the provider's name, address, telephone number, licensure and/or certification type, ownership information, and a link to driving directions. Beginning in July 2012, this information will be supplemented with links to provider-specific survey reports issued by DQA and related sources of information on providers' performance.

When the Provider Search application becomes available, it may be accessed on the DQA website at:

Back to top

Listen, Act and Live!
ReadyWisconsin Launches Tornado Awareness Campaign

With Wisconsin suddenly thrust into spring (or summer for some parts of the state) ReadyWisconsin thought it would be a good idea to get their Tornado and Severe Weather Awareness Week materials out to us a little early this year. Tornado and Severe Weather Awareness Week is April 16-20. 

The statewide tornado drill is scheduled for Thursday, April 19th. The statewide mock tornado watch will be issued at 1 pm, with the statewide mock tornado warning at 1:45 pm. This is the first time that the warning will be issued statewide rather than by weather office service areas. Also for the first time, radio, TV, and cable stations will participate in the drill. See this link for more information:

Back to top


FOCUS 2012

The Department of Health Services is pleased to announce the 11th Annual Conference for Health Care Providers and Division of Quality Assurance Staff.

The Special Session is scheduled for Wednesday, November 28, and is entitled "The Art and Science of Fall Prevention." This session is designed to address such issues as risk management, developing a culture of safety, environmental factors, effects of medications, and exercise programs. The Conference --- "Mission Possible" --- occurs on Thursday, November 29, and offers learning opportunities in the areas of assessment of altered hydration status, meeting culturally diverse needs, infection control surveillance, person-centered research, nurse delegation, new dining standards, delirium, oral care, and more.

This year's conference will be held at the Kalahari Convention Center in Wisconsin Dells. A full conference brochure and conference registration will be available on line in mid-August. For more information, go to:

Back to top


Changes in DQA Staff
Office of Caregiver Quality

Laurie Arkens- Promotion
Director / Office of Caregiver Quality

Laurie Arkens, Assisted Living Regional Director of the Bureau of Assisted Living Northeast Regional Office, was promoted to the Director of the Office of Caregiver Quality within DQA. Laurie was a member of the original management team when BAL first became a Section. Her leadership and hard work led to a number of innovative initiatives that have helped BAL become an effective and efficient regulatory agency receiving national acclaim. 

In her new role, Laurie is responsible for overall statewide oversight of the Caregiver Law requirements, including background checks and misconduct investigations, as well as federal and state nurse aide training, testing, and registry requirements. Laurie assumed her new responsibilities February 27th. Laurie will continue to assist BAL/NERO during the transition to a replacement regional director. She splits her time between DQA's central office in Madison and the regional office in DePere.

Back to top

Bill Gardner- New Employee
ALRD/ Bureau of Assisted Living (WRO)

Bill Gardner joined the Bureau of Assisted Living (BAL) effective February 13, 2012, as the Assisted Living Regional Director in the Western (Eau Claire) Regional Office. This position was formerly held by Susan Murphy who retired in December 2011.

Bill comes to BAL from the Department of Children and Families where he held the position of Licensing Chief in the Western Region since 2006. In his role as Licensing Chief, Bill supervised eight licensing specialists and three administrative support staff. His experience in supervision, enforcement of licensing rules and standards, and effectively coordinating complaint investigations will be an asset to our Division/Bureau. Bill is also an attorney licensed to practice law in both Wisconsin and Minnesota and was previously employed with the Piper Jaffray Company, Gardner and Gardner Law Firm, and Wausau Insurance Companies.

Nikki Andrews - New Employee
Quality Assurance Program Specialist - Senior / Bureau of Assisted Living (SERO)

Nikki Andrews will be joining the Bureau of Assisted Living as the Quality Assurance Program Specialist - Senior position in SERO. Nikki has worked for Dungarvin Wisconsin --- a large assisted living provider --- since 2003, holding a number of different positions. For the last five years she has served in the capacity of Area Director for both the LaCrosse and Milwaukee areas. Nikki obtained her Bachelor of Science degree from University of Wisconsin - LaCrosse. Nikki begins her position on April 23, 2012.

Update regarding Bureau of Assisted Living SERO

Carolyn Happel, Assisted Living Regional Director for the Southeast Regional Office, will be on an extended medical leave and Kevin Coughlin will be acting Regional Director for SERO. Please keep Carolyn in your thoughts and prayers during her recovery period.

Gina Bertolini - Promotion
Records and Forms Management Specialist / Bureau of Technology, Licensing, and Education

Gina Bertolini has been promoted to the position of Records and Forms Management Specialist in the Information Management Section, Bureau of Technology, Licensing, and Education. Gina has served as an Operations Program Associate in BTLE since 2007 and in that capacity has been responsible for the development of forms and publications, among many other duties. Prior to joining DQA Gina held related positions in the Division of Disability and Elder Services and the State Vital Records Office.

In her new role, Gina will be responsible for overall management of DQA's records and files, response to records requests under the state's Open Records Law, and oversight of the Division's forms/publications program. She will also assist with the planned development of DQA's electronic records management system. Gina assumed her new responsibilities beginning March 12. She is based at DQA's central office in Madison.

Sherry Walters - Transfer
Research Analyst / Bureau of Technology, Licensing, and Education

Sherry Walters has been appointed to the Research Analyst Advanced position in the Information Management Section, Bureau of Technology, Licensing and Education. Sherry has served as Assistant to the Regional Field Operations Director in DQA's Western Regional Office since 1997. Prior to that, Sherry held positions as a management information specialist at UW-Eau Claire and as a program assistant in the Western Regional Office.

In her new position, Sherry will serve as the first-level administrator of DQA's enterprise survey data system (ASPEN), providing system administration, staff training and technical support, and liaison with CMS and its contractors regarding system operations. She will also assume primary responsibility for the development and maintenance of management information reports DQA relies on and will be responsible for production of DQA's annual Consumer Information Report and liaison with facilities submitting the nursing home staffing data that is used to produce it. Sherry assumed her new position March 26. She will be based in DQA's Western Regional Office (Eau Claire).

Back to top

DQA Numbered Memos (January, February, March)
Access these memos via
or via individual providers' publications pages at

Memo No.




12-01 CMS S & C Memo 11-35 Mandate of Section 6121 of the Affordable Care Act for Nurse Aide Training in Nursing Homes CMS Survey and Certification (S&C) Memo 11-35 reports on the progress of a project mandated by Section 6121 of the Affordable Care Act to enhance the skills of nurse aides in two important areas ---caring for residents with dementia and preventing resident abuse. Nursing Homes
Nurse Aide Training Programs
12-02 Prevention of Urinary Tract Infections Use of a Catheter - Standard of Practice Resource DQA has developed the Standard of Practice Resource, Use of a Catheter (F315), for nursing homes to promote high performance standards, good resident outcomes, and to understand the federal requirements regarding prevention of urinary tract infections. Nursing Homes

Back to top

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:

S&C No.



Providers Affected
12-08 Federal Requirements for the Independent Informal Dispute Resolution (Independent IDR) Process for Federal Requirements for the IIDR Process for Nursing Homes This memo replaces S&C Memo 12-02-NH dated October 14, 2011, which discusses Federal requirements for the Independent IDR process for nursing homes. Please disregard the October 14, 2011 version. This memorandum provides interim advanced guidance Nursing Homes
12-09 Certificate and Regulatory Multiple Site Exceptions under CLIA Additional clarification and guidance is given for certifying laboratories under the various regulatory multiple sites exceptions. CLIA
12-10 Affordable Care Act and Implications for Certification of Physician-owned Hospitals The Affordable Care Act prohibits the referral of Medicare beneficiaries by physician owners or investors to new PoHs or to existing PoHs that have expanded their facility capacity beyond their baseline. An exceptions process allows some PoHs, which meet specific criteria, to expand after the baseline date. The statutory prohibition applies to physician owner referral and hospital billing activity. Hospital/CAH
12-11 Notice - Fifth Opportunity National Background Check Program Funding CMS released a fifth 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 are due February 28, 2012. Nursing Homes
12-12 Prudent Action for the FY 2012 Medicare Survey and Certification Budget It is prudent to prepare now for a lower FY2012 funding level than previously expected. CMS and States have worked to develop a variety of methods to increase efficiency and effectiveness. While these efforts may not entirely address the difference between the requested and likely budget levels, they will mitigate negative effects. Additional efforts will be necessary, and expectations for FY2012 funding will need to be adjusted. All
12-13 Use of Federally Imposed Civil Money Penalty (CMP) Funds by States Update Supersedes S&C: 11-42-NH. Beginning January 1, 2012, States must obtain prior approval from CMS for the use of federally imposed CMP funds. Nursing Homes
12-14 Home Health Survey and Certification Activities Related to Program The Home Health Prospective Payment System (PPS) final rule, CMS 1510-F, amended the regulations for HHA certification. HHAs that undergo a change in majority ownership within three years of initial Medicare enrollment or within three years of a previous change in majority ownership must enroll in the Medicare program as a new HHA, and obtain a new State survey or deemed status accreditation. Home Health Agencies
12-15 Revised Initial Certification Process for Home Health Agencies This memo revises the current process for initial certification of prospective HHAs. An additional step is added to accommodate a second review of enrollment criteria performed by the Regional Home Health Intermediary (RHHI) or Medicare Administrative Contractor (MAC). Home Health Agencies
12-16 Survey and Certification Responsibilities Related to Provider Enrollment Revocations This memo outlines the responsibilities of the Regional Office (RO) when the Medicare Administrative Contractor/Fiscal Intermediary issues a notice of revocation to a provider. All
12-17 Referring Practitioners Ordering Outpatient Services in Hospitals Outpatient services in hospitals may be ordered (and patients may be referred for hospital outpatient services) by a practitioner who is responsible for the care of the patient; licensed in, or holds a license recognized in the jurisdiction where he/she sees the patient; acting within his/her scope of practice under State law; and authorized by the medical staff to order the applicable outpatient services under a written hospital policy that is approved by the governing body. This includes both practitioners who are on the hospital medical staff and who hold medical staff privileges that include ordering the services, as well as other practitioners who are not on the hospital medical staff, but who satisfy the hospital's policies for ordering applicable outpatient services and for referring patients for hospital outpatient services. Hospitals
12-18 Hospital Patient Privacy and Medical Record Confidentiality Guidance concerning the protection of patient privacy and medical record information is clarified. This guidance is consistent with the standards under HIPAA Privacy Rule Guidance concerning permitted incidental uses and disclosures, is
clarified, and includes reasonable safeguards that must be in place to ensure patient privacy. Tags A-0441, A-0442 and A-0443 have been combined.
12-19 Living Donor Services Occurring in Transplant Programs Other than that of the Organ Recipient: Requirements and Surveyor Guidance This letter addresses Medicare requirements for transplant programs and surveyor activities in which some or all of the services for a living donor are provided by a program other than the transplant program of the organ recipient. Finalizes Interim Guidance, S&C 11-40-Transplant. This memorandum replaces the interim guidance that was previously released September 30, 2011. Transplant
12-20 Implementing the Individualized Quality Control Plan (IQCP) for Clinical Laboratory Improvement Amendments (CLIA) CMS is incorporating into the Interpretive Guidelines (IG), based on 42 CFR 493.1250, key concepts and graphics from Clinical and Laboratory Standards Institute (CLSI) Evaluation Protocol-23 (EP-23), Laboratory Quality Control Based on Risk Management, as alternative Clinical Laboratory Improvement Amendment (CLIA) Quality Control (QC) policy. CLIA
12-21 Instructions Concerning Waivers of Specific Requirements of the 2012 Edition of the National Fire Protection Association (NFPA) 101, the Life Safety Code (LSC), in Health Care Facilities - Clarification Effective Immediately This letter addresses updates to the CMS policy regarding Capacity of the Means of Egress, Cooking Facilities, Heating, Ventilating, and Air Conditioning, and Furnishings, Mattresses, and Decorations. LSC
12-22 Healthcare Associated Infections (HAI) Prevention Program Environmental Scan of State Survey Agency CMS, in collaboration with the CDC, will conduct a Healthcare Associated Infections Prevention Program Environmental Scan of State Survey Agency Training Coordinators and State HAI Coordinators. Nursing Home
12-23 INFORMATION: Reducing Avoidable Hospitalizations among Nursing Facility Residents; State Survey On Thursday March 15, 2012, CMS announced the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, a new effort designed to improve care for people living in nursing facilities who are enrolled in Medicare and Medicaid. All

Back to top

Publication Contact: Gina Bertolini
Phone: (608) 266-6691

Last Revised:  February 06, 2013