DQA Quarterly
 Information Update

July 2010

PDF Version of this month's Quarterly Update (PDF, 272 KB)

NEW THIS ISSUE

• MDS Updates
• Home Health and OASIS Information
• Counties to Have Managed Care
• RECALL:  Allen Bavarian Creme Filling
• Approved CBRF Training Program Update
• WARNING:  HITF and NFPA Code Interpretation
• DQA to Establish the Office of Plan Review and Inspection (OPRI)
  

REGULAR FEATURES

• Changes in DQA Staff
• DQA Numbered Memos
• DHS Administrative Rules Update
• CMS Survey & Certification Letters

UPCOMING EVENTS

• MDS 3.0 Basic Training
• FOCUS 2010 Conference

NEW THIS ISSUE

MDS Updates
Bureau of Technology, Licensing and
Education / Technology Services Section

RAI Manual 

CMS has made many revisions to the MDS 3.0 RAI Manual and has made training slides and instruction guides available. The RAI Manual and training materials are available on the CMS MDS 3.0 Training Materials website at: http://www.cms.gov/NursingHome
QualityInits/45_NHQIMDS30TrainingMaterials.asp

MDS 3.0 Basic Training

DQA is sponsoring MDS 3.0 provider training at multiple locations around the state in August, 2010. Training brochures and registration information were mailed to nursing homes and swing bed providers at the end of May. This information is also available on DQA's Provider Training Opportunities website at: http://www.dhs.wisconsin.gov/rl_DSL/Training/dqaProvTrng.htm

Scheduling of MDS Assessments

MDS 3.0 will be required for assessments that have an Assessment Reference Date (ARD) of 10/1/2010 or later.

MDS 3.0 assessments will use the ARD date to track when the next assessment must be completed. Comprehensive assessments must be completed at least every 366 days from the ARD date of the previous comprehensive assessment. Quarterly assessments must be completed within 92 days of the prior quarterly or comprehensive assessment ARD date.

Submission of MDS 3.0 Assessments

MDS 3.0 assessments will be required to be successfully submitted to the CMS MDS System within 14 days after the completion date of the assessment and within 14 days of the date of entry or date of discharge for tracking records. The requirement for the submission of MDS 2.0 assessments is within 31 days after the completion date.

Nursing homes will use the same method for connecting to the MDS Welcome Page to submit MDS 3.0 assessment records. The MDS Welcome Page will have a link for MDS 2.0 Submissions and a separate link for MDS 3.0 Submissions. There will be no change in the process for submitting MDS 2.0 assessment records and accessing validation reports.

MDS 3.0 assessment records will be processed directly to the MDS national database. MDS 3.0 validation reports will be available in the 'Folders' area in CASPER for nursing home staff to access and print. The Long Term Care Facility User's Guide will contain instructions for submitting MDS 3.0 assessments and accessing validation reports. This guide and the Validation Error Messages and Description Manual will be updated with MDS 3.0 information and will be available on the QIES Technical Support Office website at: www.qtso.com

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Home Health and OASIS Information
Bureau of Technology, Licensing and 
Education / Technology Services Section

OASIS-C Q&As

In April 2010, the newest OASIS Q&As were released by the Centers for Medicare and Medicaid Services (CMS) and the OASIS Certificate and Competency Board (OCCB). These two groups collaborate to release new questions and answers each quarter. The next release is scheduled for mid-July. Q&As that are directly related to OASIS-C items begin with the October 2009 Q&A set. You can obtain any of the quarterly OASIS Q&A sets at: http://occb.affiniscape.com/displaycommon.cfm?an=1&subarticlenbr=39

Home Health: Second HHQI Campaign

CMS has contracted with the West Virginia Medical Institute and Quality Insights to lead the second Home Health Quality Improvement (HHQI) Campaign. This new campaign is a grassroots movement. Under the 22-month contract, HH agencies throughout the nation are invited to register for the Campaign and to "Demonstrate your commitment to quality and improved patient care."

The HHQI Campaign released its first Best Practice Intervention Package (BPIP), entitled Introduction and Fundamentals of Reducing Avoidable Hospitalizations on January 28th, and its second BPIP, entitled Medication Management, in April. An additional BPIP, Falls Prevention, will be available July 28th. Register and/or learn more about this campaign at: http://www.homehealthquality.org/hh/default.aspx

The Campaign was kicked off at a Summit on January 13th at CMS headquarters in Baltimore, Maryland. Learn more about the Summit or access the power point presentations and audio and videos of the meeting at:
http://www.homehealthquality.org/hh/about/2010summit/default.aspx

Home Health: the CMS CAHPS Survey

The Home Healthcare Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey is designed to measure the experiences of people receiving home health care from Medicare-certified HHAs. (Participation in the HHCAHPS is optional, but will be linked to the 2012 annual payment update. Details about the HHCAHPS linkage to payment are available in the Final Home Health Payment Rule, November 10, 2009.) The HHCAHPS Survey is conducted for HHAs by approved Home Health CAHPS Survey vendors; survey results will eventually be publicly reported.

HHAs that choose to participate, must conduct a dry run for at least one of the months in the third quarter of 2010 (July, August, September 2010) and then continuously collect HHCAHPS data every month beginning in October 2010. The dry run is an opportunity for HHAs to start collection of HHCAHPS data during the period when it will not be publicly reported on Home Health Compare.

If your HHA cares for 60 or more HHCAHPS-eligible patients annually and you choose to participate, you will need to contract with a CMS-approved HHCAHPS survey vendor and perform the dry run in the third quarter. Dry run data must be submitted by January 21, 2011.

For full details about HHCAHPS, a list of approved vendors, and up-to-date news about the HHCAHPS survey process, visit: https://www.homehealthcahps.org

Additional OASIS-C Information

As CMS promised, the 'process measures manual' has finally been released! CMS is calling it PBQI: Process-based Quality Improvement. This is a 47-page manual which you can obtain by scrolling to the 'Download' section of this new PBQI webpage: http://www.cms.gov/HomeHealthQualityInits/
15_PBQIProcessMeasures.asp#

The OASIS Management of a Single Visit guide from CMS has been updated/revised as of April 2010, and can be found at: https://www.qtso.com/download/oasis/OASIS
_Mgmt_Single_Visit_at_SOC_ROC_08_05_09.pdf

WOCN revised its Quick Assessment of Leg Ulcers document as of 11/24/09. The updated document is located at: http://www.wocn.org/

As a result of HH provider feedback, CMS announced mid-June that they are developing two OASIS-C training sessions as webcasts. They anticipate that these will be ready around September and the topics will include care plan synopsis and process measures. Watch for more announcements when these become available.

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Effective July 1, 2010:
Waupaca and Winnebago Counties to Have Managed Care
Administrator's Office

Waupaca and Winnebago counties begin Family Care this July. No county start-ups are scheduled for August or September.

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RECALL: Allen Bavarian Crème Filling
Bureau of Technology, Licensing and Education

Rich Products Corporation announced nationwide voluntary recall of Allen Bavarian Crème Filling due to undeclared allergens in product.

FOR IMMEDIATE RELEASE - June 18, 2010 - Buffalo, NY - Rich Products Corporation on June 18, 2010 voluntarily recalled its Allen Bavarian Crème Filling (product code 02881) with Production codes 11870137F21, F-22, F-23, F-24, F-25, because the product may contain undeclared pecans, milk, and coconut. People who have an allergy or severe sensitivity to these ingredients run the risk of serious or life-threatening allergic reaction if they consume these products.

Rich Products Corporation has not received any reports of illness connected with this product and has issued this voluntary recall as a precautionary measure.

The pail size is 3.5 gallons. Pail weight is 31.0 lbs and the pail material is HDPE (High Density Polyethylene). Allen Bavarian Crème Filling is not packaged for retail distribution and is sold to foodservice distributors and in-store bakeries nationwide. Rich's has already notified all of its distributors and customers who have received the products in question and has directed them to remove and destroy the affected products.

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Approved CBRF Training Program Update
Bureau of Assisted Living

There are now 950 approved instructors --- 60% of whom will accept any participants and 26% of whom will travel to a location! There are 2,305 students on the registry from 585 classes taught! And, there are now three approved "Train the Trainer" programs!

Approved Instructors

Student Participants

Train the Trainer Programs

Information about the department-approved CBRF training can be found at:
http://www.uwosh.edu/ccdet/CBRF/

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WARNING: Healthcare Interpretations Task Force (HITF) and National Fire Protection Association (NFPA) Code Interpretations
Bureau of Technology, Licensing and Education

A national group of Authorities Having Jurisdiction (AHJ) meet periodically to discuss code issues and publish their interpretations to assist others in applying the National Fire Protection Association (NFPA) codes. CMS participates in this group and, when DQA queried CMS-Region 5 about their official stance on these interpretations, Bruce W. Wexelberg, AIA, provided clarification and direction:

"The HITF committee is a group of AHJs that meet twice a year to discuss questions of code interpretation consistencies and issue an opinion. The group is facilitated by NFPA staff but is not an official NFPA committee. CMS is one of the AHJs that participate. The opinions issued by the HITF are not automatically adopted by CMS as survey guidance. If CMS agrees with an opinion and feels it changes or clarifies CMS guidance, CMS will issue an S&C memo with the new guidance. S&C-07-18 issued 4/20/07 addressing corridor door gaps is an example. The State LSC surveyors should not use HITF opinions as survey guidance."

Based on this response, DQA does not encourage absolute surety in the consistency of HITF interpretations with those of CMS. CMS is the sole authority having jurisdiction for the NFPA codes and standards that it has adopted to ensure safe buildings for those facilities that wish to receive Medicare and/or Medicaid funding.

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DQA to Establish the Office of Plan Review and Inspection (OPRI)
Bureau of Health Services

On April 14, 2010, the Wisconsin Department of Administration approved the Department of Health Services' request to reorganize the Division of Quality Assurance. The reorganization created the Office of Plan Review and Inspection and will move DQA's Civil Engineer Advanced and support staff positions from the Bureaus of Health Services and Nursing Home Resident Care to OPRI. An Architect/Engineer Manager will manage and supervise OPRI.

The purpose of creating OPRI is to centralize DQA's engineering functions to one office. This move will enable DQA to manage and distribute engineering work assignments more effectively and efficiently.

Until the Architect/Engineer Manager position is filled, DQA Civil Engineer - Advanced and support staff positions will continue to report to their current supervisor and will remain in their assigned bureaus. Please watch for upcoming DQA memos that will detail the implementation of the new Office of Plan Review and Inspection.

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UPCOMING EVENTS

MDS 3.0 Basic Training
Bureau of Technology, Licensing and Education

DQA is sponsoring MDS 3.0 provider training at multiple locations around the state in August, 2010. Training brochures and registration information were mailed to nursing homes and swing bed providers at the end of May. This information is also available on DQA's Provider Training Opportunities website at:

http://www.dhs.wisconsin.gov/rl_DSL/Training/dqaProvTrng.htm

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FOCUS 2010
Bureau of Technology, Licensing and Education

November 18, 2010
FOCUS 2010 Conference: "Striving for Excellence in Challenging Times"

November 17, 2010
Special Session: "The Art and Science of Infection PREVENTION and Control"

The Wisconsin Department of Health Services, Division of Quality Assurance (DQA), is pleased to announce the 10th annual conference for health care providers and DQA staff on November 18, 2010. The Focus 2010 Conference is being developed in collaboration with health care providers and associations.

At FOCUS 2010 you will have access to leading experts in the field, the chance to network with others, and an opportunity to visit the numerous exhibit booths.

This year, the theme of the FOCUS 2010 Conference is "Striving for Excellence in Challenging Times." The agenda for this innovative conference will include topics on resident/patient abuse, caregiver ethics and boundaries, falls, dehydration, and many other topics. The keynote speaker for the day will be Karyn Buxman. Karyn's presentation is entitled "I've Got One Nerve Left and You're Standing on It!"

On November 17th, there will be an all day Special Session entitled "The Art and Science of Infection PREVENTION and Control." The Special Session will feature breakout sessions with topics that include immunizations, environmental infection control, respiratory protection, guidelines for hand hygiene, and H1N1 information. The keynote speaker for the day will be Melissa Schaefer, MD, Centers for Disease Control and Prevention. Melissa's presentation is entitled "Injection Safety."

The conference brochure will be mailed in August. At that time, you will be able to register online. Register early! The sessions will fill up quickly. As plans are finalized, information will be added to our website. Please visit:

http://www.dhs.wisconsin.gov/rl_dsl/training/focus10.htm

The conference will be held at the:

Kalahari Convention Center
1305 Kalahari Drive
Wisconsin Dells, Wisconsin
Telephone: 1-877-525-2427

When contacting the Kalahari for lodging, be sure to ask for the Focus 2010 special room rate.

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REGULAR FEATURES

Changes in DQA Staff
Bureau of Assisted Living

Thom Smith has been hired by The Bureau of Assisted Living, Southern Regional Office as a Licensing/Permit Program Associate. Thom started with BAL on May 24, 2010.

Bureau of Technology, Licensing and Education

Michelle Doro has been hired by The Bureau of Technology, Licensing and Education (BTLE) as a hospital consultant. Michelle started with BTLE on April 19, 2010. She may be reached at 414-227-4106 or at: Michelle.Doro@wi.gov

Vickie Bergquist has been hired by BTLE as a dietary consultant. Vickie started with BTLE on June 1, 2010. She may be reached at 920-983-3184 or at: Vickie.Bergquist@wi.gov

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DQA Numbered Memos (April, May, June 2010)

Listed below are DQA Numbered Memos distributed during the last quarter. You can view these memos on the internet at: http://www.dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm and http://www.dhs.wisconsin.gov/rl_DSL/

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DHS Administrative Rules Update
Administrator's Office

DHS 85 - Non-Profit Corporations as Guardians

On June 1, 2010, DHS 85, Non-Profit Corporations and Unincorporated Associations as Guardians went into effect. Significant new provisions have been added to the rule in the areas of staff qualifications, staff training, continuing education, caregiver background checks, duties and powers of the guardian, rights of wards, how to file a complaint, contacts with wards, wards' records, and conflict of interest standards. These requirements reflect the current standards of practice for non-profit corporate guardianships. For additional information regarding key provisions, training opportunities and links to additional resources, see DQA Memo 10-015 at: http://www.dhs.wisconsin.gov/rl_dsl/Publications/10-015.htm

To view the new rule, go to: http://www.dhs.wisconsin.gov/rl_dsl/Publications/pdfmemos/10-015attach.pdf

DHS 124 - Hospitals

During the early part of 2008, the Department of Health Services began working with hospitals, professional associations, advocates, and trade associations to revise Wisconsin Administrative Code, Chapter DHS 124, Hospitals. The Department is planning to update the code to eliminate overly prescriptive and outdated regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements.

While we are continuing to work on this extensive revision to the rule, new legislation makes it necessary for the Department to move forward with a limited number of revisions to ch. DHS 124 at this time. To that end, the Department amended the Statement of Scope for ch. DHS 124, dividing the revision of the rule into two separate processes.

On April 1, 2010, revisions to DHS 124, Hospitals, relating to forfeitures, anatomical gifts, and automated external defibrillator (AED) training went into effect. Revisions to the rule are posted on the Department's Administrative Rules website at: https://health.wisconsin.gov/admrules/public/Home

DHS 131 - Hospices

On December 15, 2008, the Wisconsin Administrative Rules website published a Statement of Scope of proposed rules to revise Chapter DHS 131, Hospices. The Department proposes to revise ch. DHS 131 to align the rule with revised federal Medicare regulations, to eliminate outdated regulations, and to reflect current professional standards of practice. The Department worked with the Hospice Organization and Palliative Experts (HOPE) of Wisconsin, hospices, and hospice consumers to revise ch. DHS 131.

The Proposed Rulemaking Order and Fiscal Estimate were posted on the Wisconsin Administrative Rules website on March 17, 2010. A public hearing was held in Madison on April 26, 2010. You may view the proposed rulemaking order and fiscal estimate on the Department's Administrative Rules website at: http://adminrules.wisconsin.gov/

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CMS Survey & Certification Letters (April, May, June 2010)

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 at: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

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

E-MAIL SUBSCRIPTION SERVICES

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

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Last Updated: March 21, 2013