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DQA Quarterly
Information Update

July 2012

PDF Version of this month's Quarterly Update (PDF, 136 KB)




FOCUS 2012
Bureau of Education Services an Technology

FOCUS 2012: Special Session
November 28, 2012

"The Art and Science of Fall Prevention"

FOCUS 2012: Conference
November 29, 2012

"Mission Possible!"

The Wisconsin Department of Health Services (DHS), Division of Quality Assurance (DQA), is pleased to announce the 11th annual conference for health care providers and DQA staff on November 28 and 29, 2012 at the Kalahari Convention Center in Wisconsin Dells. The Focus 2012 Conference is being developed in collaboration with health care provider and provider association representatives.

At FOCUS 2012, attendees will have access to leading experts in the health care field, the chance to network with others, and an opportunity to visit the numerous exhibit booths.

This year, the Special Session will focus on Fall Prevention. This topic is receiving special attention in order to increase both awareness of the issue and efforts to reduce the high incidence of falls in Wisconsin. This special session is intended for staff from assisted living facilities, facilities serving people with intellectual disabilities, home health agencies, hospice providers, hospitals, and nursing homes, as well as occupational therapy and physical therapy professionals, pharmacists, medical directors of nursing homes, and the Division of Quality Assurance.

The Special Session keynote speaker will feature Aleksandra Zecevic, PhD, Assistant Professor at Western University, London, Ontario. Her presentation is titled, "Understanding Falls and Falls Prevention". This presentation will provide an overview and scope of the problem, falls in diverse health care settings, injuries, cost, and prevention. Dr. Zecevic will also present a plenary session titled, "The CSI of a Fall --- A Systems Approach to Investigating Causes of Falls". This session will cover systems issues vs. person centered approaches, why falls assessments are not enough, safety culture, and how falls can help improve health care safety.

Several breakout sessions will be offered covering topics which include risk management, the effects of medications on falls, and equipment considerations.

The theme of the FOCUS 2012 Conference is, "Mission Possible!" The goal of the conference is to provide attendees with as many tools as possible to improve the health and safety of Wisconsin residents living in health care facilities. This conference is intended for staff from assisted living facilities, facilities serving people with intellectual disabilities, nursing homes, and the Division of Quality Assurance.

The keynote speaker is Dr. David Gifford, MPH, American Health Care Association and National Center for Assisted Living Senior Vice President of Quality and Regulatory Affairs. The title of his presentation is "Quality Improvement: Role of Healthcare Leadership and Regulations to Achieving High Quality Outcomes." Dr. Gifford will discuss the roles leaders play in guiding their clinical staff to achieve quality care and comply with health care regulations, using real case scenarios from different health care settings related to patient safety.

The agenda for this innovative conference includes 42 breakout sessions on topics which include hydration status, culturally diverse needs, infection control, nurse delegation, dining standards, delirium, oral care, and many other topics.

The UW Stevens Point, Education-Conference Planning Office will begin registration the first week in September. The conference/registration website is:

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Hospice Interface Agreements with Nursing Homes, CBRFs, and RCACs
Bureau of Health Services

The Bureau of Health Services recently posted updated care coordination guidelines for assisting providers in their development of contracts for the provision of services for residents, patients, and tenants who elect their hospice benefit. Three specific guidelines are developed and reflect current regulatory requirements specific to the relationships between hospice, nursing homes, CBRFs, and RCACs. These new guidelines can be found at:

Nursing Home:



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The Updated "Bad Bug Book"
Bureau of Education Services an Technology

The U.S. Food and Drug Administration has updated the "Bad Bug Book," a handbook of basic information about foodborne bacteria, viruses, parasites, prions, and naturally occurring toxins.

The updated edition of the "Bad Bug Book" is available on the FDA web site at:


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PASARR vs. MDS Change of Status Requirements
Bureau of Nursing Home Resident Care

The Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual may be downloaded from the Centers for Medicare and Medicaid Services (CMS) at:

Within Chapter 2, Assessments for The Resident Assessment Instrument (RAI), pages 2-20 through 2-27 deal with "significant change in status assessment (SCSA)." The last two of these pages refers to the interface between the "significant change in status" related to the MDS and the Preadmission Screening and Resident Review (PASARR) process. The following bullets are significant:

  • PASARR is not a requirement of the resident assessment process, but is an OBRA provision that is required to be coordinated with the resident assessment process. This guideline is intended to help facilities coordinate PASARR with the SCSA; the guideline does not require any actions to be taken in completing the SCSA itself.

  • Facilities should look to their state PASARR program requirements for specific procedures.

Wisconsin's PASARR policies are detailed in the "PASARR Requirements" which are in an attachment to the numbered memo, DDES No. 2004-16, which can be accessed at:

The requirements for a PASARR "change of status review" are provided on page two of this attachment - note that the PASARR requirement are not the same as the MDS requirements:

Beginning January 1, 1997, Wisconsin Medicaid-certified nursing facilities no longer need to have an annual resident review for any resident. Until the federal Health Care Financing Administration promulgates new regulations implementing this change in the federal law as relayed in a future informational memorandum, Medicaid-certified nursing facilities must make a referral for a "change in status" review under the following situations:

  1. A client who is admitted under a permissible short-term exemption (e.g., for a post-hospitalization recuperative care stay for up to 30 days) and needs to stay longer beyond the timeframe for the permissible exemption must be referred for a Level II Screen on or before the last day of the permitted timeframe if any of the questions in Section A of the PASARR Level I Screen are checked "yes"; 

  2. A client whose medical/physical condition improves to a level to cause the nursing facility to suspect that the client's needs could be met in an appropriate community setting, as described in the PASARR regulations and preamble, must have a resident review;

  3. A client who previously received a PASARR review and was found to need specialized services must receive a resident review if his/her level of independent functioning improves such that he/she no longer requires continuous and aggressive treatments and services to address limitations in independent functioning caused by the client's mental illness or developmental disability;

  4. A client whose independent functioning now is significantly limited as a result of a mental illness or developmental disability, but previously was not significantly limited must receive a resident review;

  5. If the responses to all questions 1 - 5 in Section A of the Level I screen for a client at the time of his/her admission to a nursing facility are checked "no" but the response to one or more of these questions should have been "yes"; or

  6. A client who previously received a PASARR review and was found to need specialized services must receive a resident review if his/her level of independent functioning declines due to a marked and permanent deterioration in his/her cognitive functioning due to dementia or health status such that he/she is unable to participate or benefit from specialized services. Note: The state and federal nursing home regulations require that the facility update the client's MDS and care plan to reflect the change in condition. Nothing in the nursing facility regulations implies that the facility should wait for the results of a new Level II screen before updating the client's care plan.

For additional information, contact:

Dan Zimmerman
PASARR Contract Administrator
Bureau of Prevention, Treatment and Recovery
1 W. Wilson Street, Room 851
Madison, WI 53703
608-267-7793 (fax)

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Accreditation of Rural Health Clinics
Bureau of Education Services an Technology

In March 2012, the Centers for Medicare and Medicaid (CMS) deemed the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) (Quad A) to accredit Rural Health Clinics. This accreditation process is available for both new and current Rural Health Clinics. Any facility accredited by the AAAASF Quad A will be automatically deemed to meet the Rural Health Clinic survey and certification standards for Medicare.

The CMS announcement and memo can be found at:


More information about certification, including applications and standards, can be accessed at:

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Changes in DQA Staff

Bureau of Education Services and Technology (BEST)

The Bureau of Licensing, Education and Technology (BTLE) is now the Bureau of Education Services and Technology (BEST). A recent restructuring effort moved the licensing staff for nursing homes, hospitals, home health, and hospice to their respective bureaus. In light of that change, BTLE has become BEST and will continue its focus on providing educational services and technology assistance to both DQA staff and providers. Alfred Johnson, BEST Director, has been appointed Interim Director of the Bureau of Assisted Living (See below for more information.); therefore, Shari Busse, Deputy Administrator, is serving as the Interim BEST Director. If you have any questions, please contact Shari at:

Kevin Coughlin - Resignation

Kevin Coughlin resigned his position with the Division of Quality Assurance and started a new assignment within the Division of Long-term Care (DLTC) starting May 7, 2012. Kevin will remain involved with DQA in a couple of areas, most notably the WCCEAL program, the collaboration with UW-Madison Center for Health Systems Research and Analysis (CHSRA). DQA is disappointed to see Kevin go, but the excellent work he has started will continue under new leadership. Best wishes, Kevin!

Alfred Johnson - Reassignment
Bureau of Assisted Living

Alfred Johnson, Director of the Bureau of Education Services and Technology (formerly BTLE), has been appointed Interim Director of the Bureau of Assisted Living effective Monday, June 4, 2012. Alfred has served in his current capacity since 2008. Prior to becoming the Director of BTLE, Alfred served as Assisted Living Regional Director in Milwaukee and prior to that in the same position in Green Bay (now DePere) office. Having someone in this role who is familiar with the industry allows the continuation of the fantastic work and collaboration that has taken place within the Bureau.

Paul Peshek - Reinstatement
Bureau of Nursing Home Resident Care / Northeastern Regional Office

Paul Peshek has returned to BNHRC as the RFOD in the De Pere Regional Office. Paul began his duties on March 26, 2012. Prior to his departure from DQA last year, Paul was the Director of the Bureau of Nursing Home Resident Care, and also served as the Regional Field Operations Director in De Pere.

Kathy Lyons - Reassignment
Bureau of Assisted Living / Northeastern Regional Office

Kathy Lyons is the new Assisted Living Regional Director for the NERO. Kathy was reassigned from her old position as the Regional Field Operation Director (RFOD) with the Bureau of Nursing Home Resident Care (BNHRC) to her new position in BAL effective May 6, 2012. Kathy comes to us with a wealth of knowledge, education, and experience in regulation and provision of services in long term care. Kathy began her career with DQA in 2003 when she joined BNHRC as a regional field operation supervisor in WRO until she was promoted to the RFOD position in 2009. Prior to her career with DQA, Kathy managed a full service medical equipment company, served as an administrator of a 100-bed nursing home, and as the Quality Assurance Director for another nursing home. Kathy holds a Bachelor of Science degree from both University of Wisconsin-Eau Claire and University of Wisconsin-Stout. She is also licensed as a Wisconsin Nursing Home Administrator.

Lynnette Traas - Reassignment
Bureau of Health Services

Lynnette Traas has accepted the Section Chief's position for the new Licensing, Certification and CLIA Section (LCCS) in the Bureau of Health Services. Lynnette is currently the Quality Assurance Program Specialist-Senior in the Bureau of Assisted Living (BAL). Lynnette comes to BHS with experience as a surveyor, prior supervisory experience, policy development, a wealth of knowledge regarding enforcement, and is experienced in interpreting regulations. Lynnette played a pivotal role in the development of best practices submitted to AHFSA; the BAL were awarded for submissions. Lynnette has a Bachelor of Science degree in Social Work and a Master of Science in Clinical Psychology.

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DQA Numbered Memos (April, May, June)
Access these memos via
or via individual providers' publications pages at

Memo No.




12-03 Independent Informal Dispute Resolution (Independent IDR) This memorandum describes the procedure under which federally certified nursing homes may dispute certain deficiencies using the Independent IDR process. Federally Certified Nursing Homes
12-04 Changes in the Division of Quality Assurance Bureau of Assisted Living - Southern Regional Office This memo informs providers of a change in location for the Division of Quality Assurance, Bureau of Assisted Living (BAL), Southern Regional Office. Adult Day Care
Adult Family Home
Community-based Residential Centers
Residential Care Apartment Complexes
12-05 Guidance for the Safe Use of Oxygen - Use of Hair Dryers This memorandum provides guidance regarding the safe use of oxygen in residential and health care facilities and was prompted by recent observations of residents using oxygen in facility beauty salons. Adult Family Homes
Community-based Residential Facilities
Facilities Serving People with Developmental Disabilities
Nursing Homes
Residential Care Apartment Complexes
12-06 2011 Wisconsin Act 161 Authorizing Physician Assistants to Complete Certain Medically-Related Actions in Nursing Homes and Community Based Residential Facilities The purpose of this memo is to provide information to health care providers regarding the new law. Community-based Residential Facilities
Facilities Serving People with Developmental Disabilities
Nursing Homes
12-07 Medication Setup in Assisted Living and Adult Day Care This memo addresses who may set up medications for residents/tenants/participants to take or for unlicensed assisted living staff or adult day care staff to administer. 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:

S&C No.



Providers Affected


Promising Practices for Implementing the Medicare Hospice Benefit for Nursing Home (NH) Resident The memo informs that CMS has developed several promising practices for the successful implementation of the Medicare Hospice Benefit for nursing home residents Nursing Homes


Use of Insulin Pens in Health Care Facilities Reports to CMS indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients. Insulin pens are meant for use by a single patient only. Sharing of insulin pens must be cited, consistent with the applicable provider/supplier specific survey guidance, in the same manner as re-use of needles or syringes. All


Environmental Scan of State Survey Agency Training Coordinators and Healthcare Associated Infections (HAI) Coordinators Nursing Home HAI Prevention programs Notification: CMS will conduct a Healthcare Associated Infections (HAI) Prevention Program Environmental Scan of State Survey Agency Training Coordinators and State HAI Coordinators.

State Selection: All states except those already contacted during pilot.

Effective Date: The environmental scan will begin in May 2012.

Nursing Homes


Patient Safety Initiative Pilot Phase - Revised Draft Surveyor Worksheets Patient Safety Initiative: CMS is testing three revised surveyor worksheets for assessing compliance with three hospital CoPs --- QAPI, Infection Control, and Discharge Planning --- as a means to reduce hospital-acquired conditions, including healthcare associated infections, and preventable readmissions.

Via this memo, CMS is making these revised draft worksheets publicly available and emphasizes that there may be additional revisions based on information gathered during the pilot test phase.

12-33 Approval of the American Association for Accreditation of Ambulatory Surgery Facilities' (AAAASFs') Rural Health Clinic (RHC) Accreditation Program CMS has recognized AAAASF as a national AO with an approved accreditation program for RHCs seeking to participate in the Medicare or Medicaid programs. This approval provides RHCs with an accreditation option which previously did not exist. Rural Health Clinics

Accreditation Organization (AO) Deeming Approval.

12-34 Clarification and revisions to Interpretive Guidance at F Tag 492, as Part of Appendix PP, State Operations Manual (SOM) for Long Term Care (LTC) Facilities This memorandum clarifies and revises the CMS guidance to Surveyors in Appendix PP of the SOM regarding citations under Tag F492. Nursing Homes
12-35 Safe Use of Single Dose/Single Use Medications to Prevent Healthcare-associated Infections Under certain conditions, it is permissible to repackage single-dose vials or single use vials into smaller doses, each intended for a single patient: The United States Pharmacopeia (USP) has established standards for compounding which, to the extent such practices are also subject to regulation by the Food and Drug Administration (FDA), may also be recognized and enforced under 501 and 502 of the Federal Food, Drug and Cosmetics Act (FDCA). All
12-36 Revised Hospital Conditions of Participation (CoPs) - Governing Revised Hospital Regulations Effective July 16, 2012: CMS has adopted a number of changes to the hospital CoPs and is in the process of developing interpretive guidelines to assist surveyors in assessing compliance under the revised regulations. Hospital

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

Last Revised:  March 21, 2013