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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

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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:

  1. Log-in to the HHQI website with your user name and password (assuming your HHA is already registered) at: www.homehealthquality.org 
  2. Click on MyLinks in the gold toolbar.
  3. 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

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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:  September 17, 2013