DQA Quarterly
Information Update
July 2011
PDF Version of this month's Quarterly Update (PDF, 135
KB)
NEW THIS ISSUE
REGULAR FEATURES
NEW THIS ISSUE
Change from AT&T to Verizon: Update for Nursing
Homes
and Home Health Agencies
Bureau of Technology, Licensing and Education
CMS is changing from AT&T to Verizon for connecting nursing homes
and home health agencies to the QIES MDS and OASIS systems. CMS has
released a migration schedule, by state, and Wisconsin is scheduled to
begin converting providers to Verizon on August 10, 2011.
Verizon will provide a clientless web-based access solution that does
not require installing software. Providers will use a link on the QIES
Technical Support Office (QTSO) website to connect to the QIES MDS and
OASIS systems for the submission of records and for accessing the CASPER
reporting system.
CMS will release additional information prior to the migration.
Providers should watch for alert messages on the MDS and OASIS Welcomes
pages and also periodically check for information on the QTSO website at: https://www.qtso.com/
The AT&T Global Client software will continue to be available during
the transition period.
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New Location: Bureau of Assisted Living /
Southern Regional Office
In order to streamline our operations, BAL / SRO staff --- previously
housed at 2135 Rimrock Road in Madison --- were moved to the Central
Office. The new contact information for the BAL / SRO is:
DQA
Bureau of Assisted Living / Southern Regional Office
1 West Wilson Street
Madison, WI 53703-3445
or
DQA
Bureau of Assisted Living / Southern Regional Office
P.O. Box 2969
Madison, WI 53701-2969
Telephone: (608) 264-9888
Fax: (608) 264-9847
See DQA Memo No. 11-018, dated June 13, 2011, for additional
information concerning these changes, including new mailing address
information at:
http://www.dhs.wisconsin.gov/rl_DSL/Publications/11-018.htm
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DQA Listserv Messages Now Available Via Web Archive
The Division of Quality Assurance is pleased to announce that an
archive of DQA listserv messages has been created on our website. There
are separate archives for each of the three listservs currently maintained
by the division --- DQA Publications, the Assisted Living Forum, and DQA
Construction. Links to the archives can be found on the main DQA web page
at:
http://www.dhs.wisconsin.gov/rl_DSL/bqa.htm
and on the division's listserv subscription page at:
http://www.dhs.wisconsin.gov/rl_dsl/Listserv/signup.HTM
At present, DQA is archiving messages sent to date during calendar year
2011 and on a go-forward basis. As staff resources permit, we will be
striving to post messages from prior years as well.
The intent of creating and maintaining these archives is to make
messages (and accompanying attachments) available to those who may have
missed them when they were originally distributed or who may have
discarded messages and now wish to refer back to them. DQA hopes providers
and others find this service useful.
If you have questions, please contact the Bureau of Technology,
Licensing and Education at 608-264-9898.
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Certificate of Waiver for Patient Testing
Bureau of Health Services
The Centers for Disease Control (CDC) has developed a postcard and
informational booklet related to Patient Testing. Getting the right test
results is important to ensure accurate treatment. Visit the links below
to obtain this valuable information. http://wwwn.cdc.gov/dls/waivedtests/GoodLaboratoryPractices.pdf
http://wwwn.cdc.gov/dls/waivedtests/ReadySetTestBooklet.pdf
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Updated CDC Guidelines for Prevention of
Intra-vascular
Catheter-related Infections
Bureau of Technology, Licensing and Education
CDC has updated the guidelines for prevention of intra-vascular
catheter-related infections (replacing the 2002 guidelines). The updated
guidelines can be accessed at: http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html
Also, CDC has issued a clinical reminder on the use of facemasks during
spinal injection procedures, which can be found at:
http://www.cdc.gov/injectionsafety/SpinalInjection-
Meningitis.html?source=govdelivery
Note that these recommendations also apply when accessing the epidural
space. "Facemasks should always be used when injecting material or
inserting a catheter into the epidural or subdural space."
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New CBRF and AFH Start-up Webcasts
Bureau of Assisted Living
The Bureau of Assisted Living recently posted a new, two-part webcast
presentation for community based residential facility (CBRF) applicants
and providers, titled "Opening and Operating a Community Based
Residential Facility." Viewing of this webcast is required for all
new CBRF providers and the "Verification of Completion - CBRF Webcast"
certificate must be included with all new applications for CBRF licensure.
Additional information and a link to the webcasts can be accessed at: http://www.dhs.wisconsin.gov/rl_DSL/CBRF/CBRFinqResp.htm
Additionally, the Bureau of Assisted Living has updated the webcast,
"Starting an Adult Family Home," for new adult family home (AFH)
providers. The revised webcast can be accessed at: http://www.dhs.wisconsin.gov/rl_DSL/AdultFamilyHomes/AFHinqResp.htm
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New Quarterly OASIS Q&A and OASIS Question M1012
In April 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 "guidance" that comes through these
Q&As becomes the newest "OASIS rules" in directing how to
answer the OASIS M-questions and is effective immediately upon release.
So, each HHA would be wise to follow these releases.
In one of the Q&As from April 2011, CMS revealed that the data gathered
by M1012 is no longer utilized by CMS for payment, quality measures, or
risk adjustment. Therefore, any response given (including 'Unknown' or
'NA') will be acceptable because the impact to your agency will be
insignificant. However, at this time the state software cannot
"accept" M1012 if left blank; it still needs to be answered,
even though for Medicare the selected response will have no impact. You
will need to continue to answer this question until further notice from
CMS. However, do keep in mind that some of your other payers require
the collection of OASIS for payment, and it's only CMS that announced it
won't be utilizing the data from M1012.
The next release of Q&As is scheduled for July 20th. The quarterly
Q&A sets are posted to the OCCB website; you can get to the Q&As
by going to the "Resources tab" at the top right of the home
page: www.oasiscertificate.org
Q&As that are directly related to OASIS-C items begin with the October
2009 set.
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OASIS-C Casper Reports and Home Care Compare Postings
CMS released a new transition timeline defining the projected
availability of all 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 (OBQM, OBQI, PBQI) should be available to providers by the
end of July, as well as the publication of OASIS-C data on the Home Care
Compare website.
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CMS-sponsored OASIS Training Videos
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.
In addition to the YouTube training videos, CMS has now released a new
educational offering that covers the HH Medication Regulations. This
"narrated PowerPoint" is about 25 minutes long and covers
"compliance" related to Medications. CMS plans to introduce two
similar modules later this year on Care Planning and Integumentary Care.
You can find the medication training on CMS' surveyor training website. Go
to this web page and select the "Provider Tools" tab: http://surveyortraining.cms.hhs.gov/index.aspx
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Home Health Quality Improvement
The second voluntary Home Health Quality Improvement (HHQI) Campaign
was scheduled to conclude on July 31st of this summer. However, CMS
recently announced the decision to continue the quality effort into the
third phase of HHQI and will continue offering free quality improvement
resources to HHAs. This is good news for HHAs, because all you need to do
to obtain these free QI tools (that relate to OASIS-C measures) is to sign
up at: www.homehealthquality.org
Details on the structure and timeline of the next HHQI phase are not
available from CMS at this time. Also, as a reminder, there have been five
free educational webinars released from this campaign, all of which are
archived for viewing, accessible here: http://www.homehealthquality.org/hh/resources/webinar/series.aspx.
HHAs should think about taking advantage of these free QI educational
materials!
CMS has closed down the former MedQIC website; this was the Medicare
Quality Improvement Community website where CMS had kept the quality
improvement tools developed during the first HHQI Campaign, which focused
upon improving outcome measures from OASIS-B1. CMS decided to close down
the website as they evolve into their 10th Statement/Scope of Work (SOW)
and beyond. To that end, CMS is working on new collaboration and web tools
to help support the "all-teach/all-learn" environment which will
address their 10th SOW goals. These tools will be rolled out over the next
several months as work begins on their 10th SOW projects. One of these
projects includes starting up a new national web presence for the QIO
Program, expected to be launched before the beginning of their 10th SOW.
However, CMS needed to close down the MedQIC site before the new site is
functional.
NOTE: The current HHQI National Campaign has chosen to
archive MedQIC's HH resources on their campaign web-site. To access those
resources:
- Log-in to the HHQI website with your user name and password
(assuming your HHA is already registered) at: www.homehealthquality.org
- Click on MyLinks in the gold toolbar.
- Click on MedQIC Resources.
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Revised 'Home Health Appendix B' of the State
Operations Manual
Since February, when CMS published the Survey and Certification
(S&C) Memo that included an "advanced copy" of revisions to
Home Health Appendix B of the State Operations Manual (SOM), CMS produced
a training webinar for HH Surveyors, teaching them to survey to the new
guidance, which became effective on 5-1-11.
CMS has recently made this webinar available to the general public,
along with the new surveyor worksheets. You can access all this
information by scrolling down on this webpage: http://www.cms.gov/OASIS/10_Training.asp#.
This webpage also includes a copy of CMS's S&C Memo which contains the
advanced copy of Appendix B. All revisions have been highlighted in red
for convenience in identifying the new/revised material.
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REGULAR FEATURES
Changes in DQA Staff
Cindy Trepes, Nurse Consultant
Bureau of Health Services / Southeastern Regional Office
Cindy Trepes is a new Nurse Consultant working out of the SERO. Cindy
will be surveying Hospitals and ESRDs.
Retirements / Resignations
Bureau of Assisted Living
I want to thank the following dedicated public servants for their
service to the people of Wisconsin and for their work in shaping the
Wisconsin Assisted Living Regulatory Process into a national model. We
wish them all bright futures. --- Kevin Coughlin, Director / BAL
- NERO Rich Levesque, Surveyor (02/23/2011 - retirement) 29 yrs
- NERO Marsha Pearson, Surveyor (04/15/2011 - retirement) 12 yrs
- SERO Mary McGrath, Surveyor (04/01/2011 - retirement) 36 yrs
- SRO Emily Schaefer , Support (05/06/2011 - resignation) 2 yrs
- SRO Jim Riordan, Surveyor (05/31/2011 - retirement) 34 yrs
- SRO Susan Blount, Regional Director (06/30/2011 - retirement) 27 yrs
New Assisted Living Regional Director
Bureau of Assisted Living / Southern Regional Office
Effective May 7, 2011, Mark Andrews was reassigned from his current
position as Section Chief of the Bureau of Health Services to the Assisted
Living Regional Director position in the Bureau of Assisted Living, a
position vacated by Susan Blount's retirement on June 30.
BAL is fortunate to have Mark back with assisted living where he began
his public service career in 2001 as a surveyor under Susan Blount's
supervision. In 2005, Mark was promoted to Quality Assurance Program
Specialist-Senior in the Bureau of Assisted Living's central office. In
2006, he was promoted to Section Chief of Bureau of Health Services where
he gained a wealth of knowledge overseeing the state's regulation,
licensing, and certification of ten separate programs with both state and
federal regulations.
Mark's background prior to state service includes Residence Director of
a 60-bed CBRF in Madison for two and a half years and member of the
administrative team for a 130-bed nursing home in Lincoln, Nebraska for
three years. Mark has a B.A. in Speech Communication from the University
of Nebraska.
Please join me in welcoming Mark Andrews --- Kevin Coughlin, Director /
BAL
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DQA Numbered Memos (April, May, June)
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/
|
Memo No. |
Title |
Summary |
Providers Affected |
|
11-009
|
Emergency Preparedness Flood Preparation and Response
|
The purpose of this memo is to share online emergency
preparedness resources developed by the Department of Health
Services regarding flood preparation and response.
|
Adult Day Care
Adult Family Homes
Ambulatory Surgery Ctrs
Certified Mental Health and AODA Programs
CLIA
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
|
|
11-010
|
Notice of Department Designee for CBRF
Department-Approved Assisted Living Administrator Training
|
On April 1, 2009, the revised Chapter DHS 83, Wis.
Admin. Code, for CBRFs was implemented. With this implementation,
there are new qualification requirements for CBRF administrators.
|
Community Based Residential Facilities
|
|
11-011
|
Residents' Transfer and Discharge Protections
|
The purpose of this memo is to remind nursing home
providers of the protections afforded to residents going through a
transfer or discharge process.
|
Nursing Homes
|
|
11-012
|
Alternate Suppression Systems for Elevator Machine
Rooms
|
CMS requires the use of the 2000 edition of the
National Fire Protection Association (NFPA) 101 Life Safety Code (LSC),
which requires the use of the 1999 edition of NFPA 13, Standard for
the Installation of Sprinkler Systems.
|
Ambulatory Surgical Ctrs
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Hospices
Hospitals
Nursing Homes
|
|
11-013
|
Pre-admission Consultation Requirements (PAC)
Revised Requirements - Effective Immediately
|
This memo describes changes in the requirements for
community based residential facilities, nursing homes, and
residential care apartment complexes to make referrals and provide
information to prospective residents.
|
Community Based Residential Facilities
Nursing Homes
Residential Care Apartment Complexes
|
|
11-014
|
Summary of the Division of Quality Assurance
Provider Post-Survey Questionnaire |
The purpose of this memo is to share information
regarding the results and use of the DQA Post-Survey Questionnaire
and to encourage all providers to utilize this tool to give the
Division constructive feedback on the survey process.
|
Adult Day Care
Adult Family Homes
Ambulatory Surgery Ctrs
Certified Mental Health and AODA Programs
CLIA
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
|
|
11-015 |
Life Safety Code Waiver Requests |
The purpose of this memo is to clarify how Life
Safety Code NFPA 101 (LSC) waiver requests should be developed by
Medicare and Medicaid participating health care providers. Overall,
the number of denied requests has resulted in a significant increase
in work for all parties involved. |
Ambulatory Surgical Centers
End Stage Renal Dialysis Units
Facilities for the Developmentally Disabled
Hospice
Hospitals
Nursing Homes |
|
11-016 |
Guidelines for Use of Sign-Language Interpreter in
Nurse Aide Training Program |
The purpose of this memo is to provide guidelines
for the use of a sign-language interpreter for a deaf or hard of
hearing student enrolled in an approved nurse aide training program. |
Nurse Aide Training Programs |
|
11-017 |
Electronic Signatures on Health Care Documents |
With the development of electronic record-keeping,
various options exist to electronically obtain and store a health
care patient's or resident's signature for necessary documents. |
Adult Family Homes
Ambulatory Surgery Ctrs
Certified Mental Health and AODA Programs
CLIA
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 |
|
11-018 |
Changes in the Division of Quality Assurance
Southern Regional Office - Bureau of Assisted Living |
The purpose of this memo is to inform providers of
changes in the DQA, Southern Regional Office, Bureau of Assisted
Living. |
Adult Day Care Centers
Adult Family Homes
Community Based Residential Facilities
Residential Care Apartment Complexes |
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CMS Survey & Certification Letters (April, May,
June)
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 |
|
11-18-NH |
Final Rule for Skilled Nursing Facilities (SNF) and
Nursing Facilities (NF) |
The Interim Final Rule with comment, Notification
of Facility Closure, was published in the Federal Register on
02/18/11. The Patient Protection and Affordable Care Act under
section 1128I (h) mandates specific procedures in the event of a SNF
or (NF) closure that help protect the resident, the resident's
family, and visitors. |
Nursing Homes |
|
11-19-CLIA |
Notification of Withdrawal of CMS 2252-P -Cytology
Proficiency Testing NPRM |
The majority of recommendations made by the cyto-pathology
and cyto-technology experts and the Clinical Laboratory Improvement
Advisory Committee (CLIAC) will be implemented through revised
interpretive guidance and administrative policy. |
Clinical Laboratories |
|
11-20-All |
Contingency Plans - State Survey &
Certification |
This memo was not issued and there will be no
download. |
All |
|
11-21-ASC |
Clarifications to the ASC Interpretive Guidelines |
ASCs may not limit surveyor ability to observe
patient care. Surveyors are not required to sign documents, provide
proof of vaccinations, or obtain the consent of the operating
physician in order to observe a surgical procedure. Surveyors will
obtain patient's consent and conduct themselves in a manner that
protects patient safety and that does not interfere with the
operating physician or procedure. |
Ambulatory Surgery Centers |
|
11-22-NH |
QAPI Initiatives Related to Section 6102 (c) of the
Affordable Care Act |
The purpose of this memo is to advise of
initiatives that CMS is undertaking to implement mandates of Section
6102 (c) of the Affordable Care Act related to Quality Assurance and
Performance Improvement |
Nursing Homes |
|
11-23-NH |
Notice - Third Opportunity National Background
Check Program |
CMS has issued a third multi-year National
Background Check Program for Patient Protection solicitation for
Federal matching grants to all States and the U.S. Territories that
did not submit proposals during the first two solicitations. States
that applied during the first two solicitations, but did not receive
the full award amount, may apply for the remaining amount allowed
under the provisions of the law at section 6201 of the Affordable
Care Act. |
Nursing Homes |
|
11-24-All |
New Initiative: Partnership for Patients: Better
Care, Lower Costs |
On April 12, 2011, Secretary Kathleen Sebelius and
CMS Administrator Donald Berwick announced the Partnership for
Patients: Better Care, Lower Costs, a new public-private partnership
that will help improve the quality, safety, and affordability of
health care for all Americans. |
All |
|
11-25-PSYCH |
Clarification of 482.61(b (3): Requirements for a
Screening Neurological Examination |
This memo provides clarification for the complete
neurological examination, with guidance, and testing intellectual
functioning, memory functioning, and orientation with guidance. |
Psychiatric Providers |
|
11-26-AO |
Approval of Deeming Authority of the Joint
Commission for Psychiatric Hospitals |
CMS has approved the Joint Commission as a national
accreditation program for psychiatric hospitals seeking to
participate in the Medicare or Medicaid programs. |
Psychiatric Hospitals |
|
11-27-AO |
Approval of Deeming Authority of the American
Association for Accreditation of Ambulatory Surgery Facilities |
CMS has approved the American Association for
Accreditation of Ambulatory Surgery Facilities, Inc. as a national
accreditation program for providers of outpatient physical therapy
and speech-language pathology services seeking to participate in the
Medicare or Medicaid programs. |
Ambulatory Surgery Centers |
|
11-28-Hospitals |
State Operations Manual (SOM) Hospital Appendix A
Update |
This memo provides CMS clarification of guidance
related to training requirements for personnel administering blood
transfusions and intravenous medications and to the requirement for
immediate reporting of drug administration errors, adverse drug
events, and incompatibilities. Attached is an advance copy of the
SOM Appendix A reflecting these updates. |
Hospitals |
|
11-29-Transplant |
Verification of Recipient and Donor Blood Type and
Other Vital Data |
This memo provides clarification of CMS guidance to
the CMS Regional Offices, State Survey Agencies, and the CMS
contractor involved in the survey and certification activities of
organ transplant programs related to the verification of blood type
(ABO) and other vital data per CoP, Organ Recovery
and Receipt (42 CFR 482.92). |
Organ Transplant Programs |
|
11-30-NH |
Reporting Reasonable Suspicion of a Crime in a
Long-Term Care Facility |
In order to promote timely application of the
protections offered by section 1150B of the Act for LTC facility
residents, CMS explains the current obligations of LTC facilities to
comply with the law as it is plainly written, without any delay that
might be occasioned by waiting for any administrative rule-making
process that might further clarify application of the law. |
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:
October 19, 2012
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