DQA Quarterly Information Update
January 2010
PDF Version of this month's Quarterly Update (PDF,
192 KB)
NEW THIS ISSUE
REGULAR FEATURES
UPCOMING EVENTS
NEW THIS ISSUE
Change in Hospital and Non-LTC Complaint Information
Bureau of Health Services
Due to the retirement of Helen Brewster, Hospital and
Non-Long Term Care Complaint Coordinator, her direct telephone number will
no longer be used. Please remove Helen's direct number --- 608-266-0224 ---
from your list of resources and refer complainants to 1-800-642-6552
(hotline) or 608-266-8481 (DQA main number).
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DHS 83 Implementation Continues
Bureau of Assisted Living
With the promulgation of DHS 83 effective April 1, 2009, DQA/BAL
has implemented a number of initiatives to ensure a smooth transition to
this major rule change. Following is a list of DQA Numbered Memos and
materials that provide summaries of some of those changes:
09-005 Training
http://www.dhs.wisconsin.gov/rl_DSL/Publications/09-005.htm
09-007 Previously Issued Memo Crosswalk
http://www.dhs.wisconsin.gov/rl_DSL/Publications/09-007.htm
09-031 Statewide Waiver
http://www.dhs.wisconsin.gov/rl_DSL/Publications/09-031.htm
09-045 Department Designee for CBRF Approved Training
http://www.dhs.wisconsin.gov/rl_DSL/Publications/09-045.htm
09-046 Department-approved Assisted Living Administrator Training
Course
http://www.dhs.wisconsin.gov/rl_DSL/Publications/09-046.htm
DHS 83 Q & A Document
http://www.dhs.wisconsin.gov/rl_DSL/CBRF/dhs83Q&A09.pdf
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Bureau of Assisted Living Wins AHFSA Awards
Bureau of Assisted Living
Wisconsin won first place from the Association of Health Facility Survey
Agencies (AHFSA)in the Education Category for its submission,
"Medication Management Initiative", a web-based resource available
at: http://www.dhs.wisconsin.gov/rl_dsl/MedManagement/asstlvgMMI.htm
Wisconsin also won first place in the Quality Improvement Category for
its submission, "Facilitating Compliance with Deferred
Revocation". Kevin Coughlin, Director, accepted the awards at the AHFSA
annual conference in San Antonio, Texas on October 6th. http://ahfsa.org/Promising%20practices.htm
In addition, Wisconsin was featured in two assisted living conference
breakout sessions for "Medication Management in Assisted Living"
and "State Collaboration with Other Agencies - Assisted Living".
More information can be found at the AHFSA website: http://www.ahfsa.org/
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Approved Sprinkler Systems for Small Class C Community
Based Residential Facilities
Bureau of Assisted Living
With the promulgation of DHS 83 on April 1, 2009, § DHS
83.49 requires that all small Class C CBRFs must have an approved Sprinkler
System by 4/1/2014. In addition, § DHS 83.63 requires a plan review for the
installation of a sprinkler system. Chapter DHS 83 is available at: http://www.legis.state.wi.us/rsb/code/dhs/dhs083.pdf
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Calumet County to Have Managed Care
Administrator's Office
Effective January 1, 2010: Calumet County
On June 19, 2009, the Division of Quality Assurance issued DQA memos
09-023 (CBRFs), 09-024 (RCACs), and 09-025 (Nursing Homes) outlining the
Preadmission Consultation (PAC) requirements for providers, effective July
1, 2009. The memoranda are available at:
http://www.dhs.wisconsin.gov/rl_dsl/Publications/11-023.htm
http://www.dhs.wisconsin.gov/rl_dsl/Publications/09-024.htm
http://www.dhs.wisconsin.gov/rl_dsl/Publications/09-025.htm
The memoranda identify certain information dissemination and referral
responsibilities that affect facilities in counties with Managed Care/IRIS
(self-directed supports waiver) and in counties where Medicaid Waiver
programs are available. Currently, managed care is not available in all
counties.
When managed care is made available in a county, the new PAC
requirements take effect. DQA will continue to publish the Managed Care
Organization (MCO) start dates in the DQA Quarterly Information Update to
inform providers when the new PAC requirements go into effect.
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Home Health: OASIS-C
Bureau of Technology, Licensing and Education
For all federally certified Home Health Agencies (HHAs), the OASIS-C
dataset is replacing the OASIS-B1 dataset, effective January 1, 2010. HHAs
must collect OASIS information on their patients in order to participate in
the Medicare program.
Comprehensive assessments containing OASIS questions will transition as
determined by the M0090 completion date: M0090 dates of 12/31/09 or before
will use the B1-dataset; M0090 dates of 1/1/2010 or after will use the
C-dataset.
If the wrong dataset is used, the State OASIS System will reject the
assessment. HHAs can include both OASIS-B1 and OASIS-C assessment records in
the same submission file. HHAs should obtain/print the updated Error Message
and Description Guide that is available on the QIES Technical Support Office
website at: www.qtso.com
Under the OASIS-C guidelines, OASIS questions --- as part of each
patient's comprehensive assessment --- will still apply only to
Medicare/Medicaid skilled adult non-maternity patients. Previously, HHAs
could submit assessment records for patients where OASIS did not
apply. These records would appear on the Final Validation report as
"masked" records and actual patient identifiers were not saved in
the State OASIS database. Effective with OASIS-C, records transmitted where
OASIS data was not required will be rejected on the Final Validation report.
In 2010, CMS will implement security regulations that will change the way
HHAs login to the State OASIS System, including CASPER. Currently HHAs use
an agency-assigned shared login ID and password. When the security changes
are deployed, each user will be required to register for an individual user
ID using a link on the State OASIS Welcome page. HHAs should regularly check
the OASIS Welcome page for additional information about this upcoming
security change.
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OASIS Resources
Bureau of Technology, Licensing and Education
The Center for Medicare and Medicaid Services (CMS) provided three free
national Medicare Learning Network (MLN) "OASIS-C
Train-the-Trainer" conference calls on topics related to OASIS-C.
Although these calls have been completed (one each in October, November, and
December), transcripts of these calls are --- or will be --- posted on the
CMS website under 'Downloads'at: http://www.cms.hhs.gov/HomeHealthQualityInits/03_EducationalResources.asp#
Handouts/slides for these conference calls are available under 'Downloads'
at: http://www.cms.gov/
CMS announced that the new OASIS-C Guidance Manual will be updated as a
result of questions that arose during the three MLN conference calls. Though
the revision is not yet posted, the "content" that will be changed
can be found in the document "OASIS-C Guidance Manual Errata"
under 'Downloads' at:
http://www.cms.hhs.gov/HomeHealthQualityInits/
14_HHQIOASISUserManual.asp#
Also, a helpful comparative "Crosswalk from B1-to-C" can be found
in Appendix G of the new Guidance Manual.
In addition, several personnel from and contractors to CMS (who were
responsible for the development and testing of OASIS-C) gave presentations
on OASIS-C in October at the National Association of Home Care and Hospice's
(NAHC) convention. The four presentations have been made available to the
public and slides are available for viewing at: http://www.dcprovidersonline.com/nahc/?event_id=NAHC102
The new July 2009 version of "OASIS Considerations for Medicare PPS
Patients" was posted in November at: https://www.qtso.com/hhadownload.html
The new "2010 OASIS Follow-up Assessment Scheduling Calendar"
is also available at this site.
In October, CMS and the OASIS Certificate and Competency Board (OCCB)
released 45 new Q&A's related to the use of the OASIS-C dataset that
HHAs will want to view at: http://oasiscertificate.org/main/
CMS also plans to release new Wound, Ostomy, and Continence Nurses' (WOCN)
guidance related to the new OASIS-C wound questions, when it becomes
available. Revised OBQI and OBQM manuals and a new Process Measure Manual
will also be available in the future.
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New Home Health Quality Measures
Bureau of Technology, Licensing and Education
OASIS-C is the first major update to the OASIS dataset since its
introduction. There are significant revisions to existing elements,
elimination of some data elements, and the addition of new elements that are
capable of capturing new process and outcome measures. Some of the new
process elements will collect data on processes of care that HHAs might use
in caring for their patients, which will enable calculation of the HHA's use
of "best practices."
Previously, home health quality measures focused only on patient outcomes.
The new process data items will allow the measurement of processes of care
that are under the agency's control and will be used to "give
credit" to HHAs that are incorporating evidence-based practices into
their patients' care.
CMS does not plan to merge OASIS-B and OASIS-C quality measures in the
OBQM and OBQI reports. B1 Casper reports will be available for HHAs and on
Home Care Compare until all reports that utilize data through 12/31/09 have
been published. Following, there will be a "blackout period" where
no new reports will be available because (1) publishing quality reports with
too little data carries risks that reports could be inaccurate or misleading
and (2) risk-adjustment models have not yet been developed for OASIS-C.
Taking 'report lag time' into consideration, the first OBQM Casper
reports will be available in May or June 2010 and will be renamed
"Potentially Avoidable Events." New process measure reports and
Home Care Compare reports may be available in September or October 2010, and
Outcome Casper reports are expected to reflect OASIS-C measures by
approximately May 2011.
Descriptions of the revised quality measures and draft report formats
will be posted on the CMS OASIS-C website at: www.cms.gov/
Questions regarding any OASIS-related information can be directed to
either of the following:
Mary Jo Sutton, OASIS Education Coordinator
MaryJo.Sutton@wi.gov
920-983-3188
Chris Benesh, OASIS Automation Coordinator
Chris.Benesh@wi.gov
608-266-1718
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OASIS E-mail Group
Bureau of Technology, Licensing and Education
In August 2008, DQA sent a questionnaire to Home Health Agencies (HHAs)
in Wisconsin, asking for provider input on DQA plans for future OASIS
trainings. One questionnaire item asked whether the HHA was interested in
joining an OASIS communications e-mail group (listserv) that could be used
to send OASIS-related information to HHAs. The overwhelming response to this
question was "Yes!"
Since that time, it was determined that creation of a listserv limited to
HHAs could not be undertaken for multiple reasons. DQA is still interested
in creating an e-mail group not hosted by the state listserv system for
dissemination of OASIS information.
However, in order to join such a group, HHAs would need to have (or be
able to create) a non-personal e-mail box to which messages could be sent.
Such mailboxes might take the form "oasis@hhaname.com" or
"oasis@hhaname.org."
If your agency is interested in joining such an e-mail group and
has or can establish this type of "oasis@" mailbox, please e-mail
your name, title, and the mailbox address for your HHA to: MaryJo.Sutton@wi.gov
DQA will then tabulate responses and determine the feasibility of
establishing this program. If you have questions, please contact Mary Jo
Sutton, OASIS Education Coordinator, at the above e-mail address or by
telephone at 920-983-3188.
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MDS 3.0 Implementation
Bureau of Technology, Licensing and Education
The Minimum Data Set (MDS) 3.0 is scheduled for implementation on October
1, 2010. MDS 3.0 includes many improvements that will have profound
implications for nursing home and swing-bed care and public policy. One of
the areas that has changed replaces Resident Assessment Protocols (RAPs)
with Care Area Triggers (CATs). Nursing home and swing-bed facilities should
be planning for this implementation by familiarizing staff with the MDS 3.0.
CMS posts MDS 3.0 materials at: www.cms.hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp
The website currently includes the following information:
- RAI Manual Chapters 1, 3, and 5 and many of the Appendices. (Chapters
2, 4, and 6 and Appendix C are scheduled for posting in December.)
- Item Subsets (V1.00) - data items required for each assessment type.
- Item Matrix (V1.00) identifies data items used for CATs, Quality
Measures, Quality Indicators, RUG-IV, and RUG-III.
- Technical information including detailed data submission
specifications, logic for calculation of RUG-IV and RUG-III
classifications, and triggering logic for the CATs.
On December 17, the CMS sponsored a live satellite broadcast and webcast
entitled "MDS 3.0: Part I - An Introduction." This program is the
first of a three-part series focused on providing information about MDS 3.0.
This webcast can be viewed up to a year after December 17, 2009. Nursing
home providers can view the archived broadcast by clicking on
"Satellite Broadcast" or "Archived Webcast" at: http://surveyortraining.cms.hhs.gov
Non-surveyors do not need to register. For complete details regarding
this broadcast, see the "Bulletins" area of the State MDS Welcome
page.
The Division of Quality Assurance will be offering provider training on
the MDS 3.0 in spring/summer of 2010.
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MDS 2.0 State Specified Quarterly Assessments
Bureau of Technology, Licensing and Education
The State specified, two-page MDS Quarterly Assessment form has been
changed to a larger MDS MPAF Quarterly Assessment form. Nursing homes were
given a transition period to update their software programs with this
change. Starting in January 2010, the State MDS System will reject MDS
Quarterly Assessment records that do not include MPAF data items.
Nursing homes must complete and submit MDS MPAF Quarterly assessments to
meet the Quarterly Review and Automated Data Processing federal
requirements.
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REGULAR FEATURES
Changes in DQA Staff
Lydia Reitman
Long time DQA Nursing Consultant, Lydia Reitman, passed away on October 10,
2009.
Tina Lubick
Bureau of Nursing Home Resident Care (SRO) - Transfer to Bureau of Assisted
Living 12/05/09
Martha Janeice Armes
Bureau of Nursing Home Resident Care (SRO) - Retired 08/01/09
Helen Brewster
Bureau of Health Services (CO) - Retired 12/11/09
Linda Szfranski
Bureau of Nursing Home Resident Care (SERO) - Retired 12/17/09
Diane Caruso
Bureau of Assisted Living (SERO) - Retired 12/30/09
Kitty Friend
Bureau of Technology, Licensing and Education (SERO) - Retired 12/30/09
Peggy Ramer
Bureau of Nursing Home Resident Care (SRO) - Retired 01/06/10
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DQA Numbered Memos (October, November, December)
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/
DQA Memos
|
Memo No.
|
Title
|
Summary
|
Providers Affected |
| 09-040 |
For All Facilities Performing Tests on Human Specimens:
CLIA Requirements
|
Under the authority of Section 353 of the Public Health
Service Act, the Clinical Laboratory Improvement Amendments of 1988 (CLIA)
require all facilities performing tests on human specimens to be
certified to perform these tests. The regulations that implemented
CLIA became effective September 1, 1992.
|
Ambulatory Surgery Centers
Adult Day Care Centers
Adult Family Homes
Certified Mental Health and AODA
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
Residential Care Apartment Complexes
Rural Health Clinics
|
| 09-041 |
Emergency Preparedness Resource Inventory Registration
System Now Online
|
This memo announces the availability of online
registration for the CMS Emergency Preparedness Resource Inventory (EPRI)
system.
|
Ambulatory Surgery Centers
Adult Day Care Centers
Adult Family Homes
Certified Mental Health and AODA
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
Residential Care Apartment Complexes
Rural Health Clinics
|
| 09-042 |
Palliative Care
|
The purpose of this memorandum is to provide information
and guidance on the meaning of palliative care and expectations for
palliative and supportive care programs.
|
Home Health Agencies
Hospitals
Nursing Homes
|
| 09-043 |
Notice of Implementation of Revisit Fee
|
This memorandum outlines the implementation of an
inspection (revisit) fee assessment for Community Based Residential
Facilities (CBRFs), Adult Family Homes (AFHs), Residential Care
Apartment Complexes (RCACs), and Adult Day Cares (ADCs), consistent
with the enactment of the state budget bill, Wisconsin Act 28, which
became effective June 29, 2009.
|
Adult Day Care Centers
Adult Family Homes
Community Based
Residential Facilities
Residential Care Apartment
Complexes
|
| 09-044 |
Invitation to Nursing Home Stakeholders to Apply for
Grants for Use of Civil Money Penalty (CMP) Funds
|
The purpose of this memo is to announce the availability
of grant funding from the civil money penalty (CMP) program that can
be used to benefit Wisconsin nursing home residents.
These grants are
available for projects or programs that are provided through various
interested nursing home stakeholders; e.g., facilities, consumer
groups, professional nursing home associations, ombudsmen program,
quality improvement organizations, etc.
|
Nursing Homes
|
| 09-045 |
Notice of Department Designee for CBRF
Department-Approved Training
|
On April 1, 2009, the Department implemented the revised
Wis. Admin. Code, ch. DHS 83, licensing standards and regulations for
CBRFs.
Minimum training requirements for CBRF personnel changed
substantially with a delayed implementation date of April 1, 2010 for
all current department approved CBRF training plans and approved
trainers.
|
Community Based
Residential Facilities
|
| 09-046 |
Department-Approved Assisted Living Administrator's
Training Course
|
On April 1, 2009, the revised Wis. Admin. Code, Chapter
DHS 83 for CBRFs was implemented, establishing new qualification requirements
for CBRF administrators.
The department has developed curriculum criteria and trainer
requirements that will be utilized in the department review and approval process
|
Community-Based Residential Facilities
|
| 09-047 |
Changes in 2010 to WI Clean Indoor Air Act and Its
Effect on Nursing Home Smoking Policies
|
Effective July 5, 2010, the Wisconsin Clean Indoor Air
Act will prohibit smoking in all inpatient health care facilities,
including nursing homes, within the state of Wisconsin.
This memo updates and replaces DDES-BQA-05-008, which was issued June
15, 2005. This memo is being sent at this time so that staff and
residents can prepare for any changes that will need to be implemented
by July 5, 2010.
|
Nursing Homes
|
| 09-048 |
Notice of Change in Certification Fees for Mental Health
and Substance Abuse Services Providers
|
This memo announces changes in the annual certification
fees for mental health and community substance abuse programs and
services.
|
Certified Mental Health and Substance Abuse Services
Providers
|
| 09-049 |
Notice of Change in Certification Fees for Mental Health
and Substance Abuse Services Providers to take effect on Counties in
2011
|
This memo announces changes in annual certification
fees for county mental health and community substance abuse programs
and services.
|
Wisconsin County Departments of Human Services
Community Services
|
| 09-050 |
Staffing of Facilities and Programs During a Pandemic
|
This memo expands upon information previously provided
in DQA Memos 09-018, 09-020, and 09-030 regarding Novel Influenza A
(H1N1) / 2009 (Swine Flu).
The purpose of this memo is to identify planning resources for
staffing shortages when a pandemic is occurring.
|
Ambulatory Surgery Centers
Adult Day Care Centers
Adult Family Homes
Certified Mental Health and AODA
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
Residential Care Apartment Complexes
Rural Health Clinics
|
| 09-051 |
Domestic Partnership - Chapter 50 Information Update
|
This document summarizes the rights of domestic partners
in health care settings relating to accompaniment or visitation,
resident rights, and consent to admission to certain facilities.
|
Adult Family Homes
Community Based Residential Facilities
Hospitals
Hospices
Nursing Homes
Residential Care Apartment Complexes
|
| 09-052 |
Plans of Correction Via Attestation for Assisted Living
Facilities
|
This memo announces that, in specified situations, the
Bureau of Assisted Living will accept an attestation of compliance as
a facility's plan of correction.
|
Adult Day Care Centers
Adult Family Homes
Community Based Residential Facilities
Residential Care Apartment Complexes
|
| 09-053 |
Webcast Presentation
F441: Infection Control - Guidance to Surveyors
|
On July 20, 2009, CMS issued revisions to Appendix PP -
Interpretive Guidelines for Long Term Care Facilities for F-tag 441.
These updated guidelines became effective September 30, 2009.
DQA is making this webcast available to enable viewers to (1) identify
and describe the revisions to the interpretive guidelines for
infection control; (2) demonstrate knowledge of the contents of the
revised guidance to surveyors for F441; (3) appropriately and
accurately utilize the revised guidance and investigative protocol
during the survey process.
|
Nursing Homes
|
| 09-054 |
Cleaning and Disinfecting Glucose Meters Shared Between
Residents
|
This memo provides information and guidance regarding
the cleaning and disinfecting of glucose meters that are shared
between residents in the facility and notifies that, effective
immediately, the revised guidance at F441, issued by the Centers for
Medicare and Medicaid Services (CMS) on 11/30/09, directs surveyors to
cite at the level of immediate jeopardy the deficient practice of
failing to clean and disinfect the shared glucose meter between
residents.
|
Nursing Homes
|
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DHS Administrative Rules Update
Administrator's Office
DHS 85 - Non-Profit Corporation as Guardian
On September 19, 2006, the Wisconsin Administrative Register
published a Statement of Scope of proposed rules to amend Chapter DHS 85,
Non-profit Corporation as Guardian. Through this initiative, the Department
proposes to make the rule reflect current standards of practice, recognizing
the increase in the number of adults in need of guardianship and the
increase in the complexity of their needs.
An Advisory Committee, including advocates, providers,
registers in probate, and County adult protective services staff, met and
reviewed proposed rule language and made recommendations for change. The
proposed rule was filed with the Clearinghouse and Legislative Reference
Bureau on August 12, 2009. Public hearings on the proposed rule were held on
October 8 in Waukesha and on October 14 in La Crosse.
The Rule Order and Fiscal Estimate for Chapter DHS 85, Private Non-profit
Corporations and Unincorporated Associations as Guardians, has been posted
on the Department's Administrative Rules website at the following link: https://health.wisconsin.gov/admrules/public/Home
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. 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.
The Rule Order and Fiscal Estimate for Chapter DHS 124, Hospitals,
relating to forfeitures, anatomical gifts, and automated external
defibrillator (AED) training, was posted on the Department's Administrative
Rules website on October 23, 2009. A public hearing on the proposed rule was
held on December 14, 2009 in Madison. For more information, you may view the
Rule Order and Fiscal Estimate on the Wisconsin 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 has asked the Hospice Organization and Palliative Experts
(HOPE) of Wisconsin, hospices, and hospice consumers to participate in
revising ch. DHS 131. For more information, you may view the Statement of
Scope on the Wisconsin Administrative Rules website at: https://health.wisconsin.gov/admrules/public/Home
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CMS Survey & Certification Letters
(October, November, December)
Listed below are Survey and Certification
(S&C) Letters distributed by 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 Memos
|
S&C No. |
Title |
Summary |
Providers Affected |
|
10-01 |
Treatment of Subpoenas Duces Tecum for Federal and
Joint Federal/State Documents |
This memo provides guidance for handling of subpoenas
duces tecum that seek disclosure of records in the possession of the
State Survey Agency (SA) as a result of the SA's implementation of its Agreement with the Secretary,
Health and Human Services, under Section 1864 of the Social Security
Act (1864 Agreement). Guidance contained herein is based upon 45 C.F.R.
Part 2, as amended by 73 FR 53148, dated September 15, 2008. It is effective immediately and supersedes previous instructions
related to subpoenas for records treated as Freedom of Information
requests. |
State Survey Agency Directors |
|
10-02 |
H1N1 Flu Vaccinations or Other Emergency Activities |
This memo provides information that CMS will work
with the SAs on a case-by-case basis to adjust work schedules and
other survey and certification actions if State emergency response
authorities determine that they must deploy surveyors to administer
vaccinations and the State has determined no alternative strategies
are available. |
State Survey Agency Directors |
|
10-03 |
Approval of State and National Certification Programs
for Dialysis Technicians Under New ESRD CFCs |
The new ESRD Conditions for Coverage requires
dialysis patient care technicians (PCTs), who have been employed since
October 14, 2008, to be certified by either a State or National PCT
certification program by April 15, 2010. PCTs hired after October 14,
2008 must be certified within 18 months of their date of hire. |
State Survey Agency Directors |
|
10-04 |
Waiver to Allow Hospitals to Use the NFPA 6-Year
Damper Testing Interval |
This memo permits hospitals to apply the NFPA 6-year
testing interval for fire and smoke dampers in hospital heating and
ventilating systems, so long as the hospital's testing system conforms
to the testing requirements under the 2007 edition of NFPA 80 and NFPA
105. |
State Survey Agency Directors |
|
10-05 |
EMTALA Regulation Changes and H1N1 Pandemic Flu and
EMTALA Waivers |
The Fiscal Year (FY) 2010 Inpatient Prospective
Payment System (IPPS) Final Rule included technical revisions
concerning the non-applicability of EMTALA sanctions under Section
1135(b)(3) of the Social Security Act (the Act). During a public health emergency, waivers under section 1135(b)(3) can
provide exceptions to penalties for the otherwise impermissible
redirection or relocation of individuals for a medical screening examination (MSE)
and for inappropriate transfers. In this memo we describe the waiver process
for these EMTALA-specific waivers |
State Survey Agency Directors |
|
10-06 |
Presidential Emergency Declaration and HHS Section
1135 Waiver Authorization |
Secretary Sebelius exercised her waiver authority
under section 1135 of the Social Security Act, effective October 23,
2009. The Secretary has delegated to the CMS the determination for a
waiver for each case justified by necessity and extent [other than for
the Health Insurance Portability and Accountability Act (HIPAA) waivers permitted under section 1135]. H1N1 Tracking Tool for
State Agency (SA) Staffing: Attachment 1 contains a tracking tool to
assist States in reporting any H1N1 influenza impact to their survey
and certification activities. |
State Survey Agency Directors |
|
10-07 |
Consolidation of Personnel Policies for Individuals
Directing or Performing Non-waived Tests |
Presently, CLIA-related personnel policies and
procedures are dispersed throughout the regulations, State Operations
Manual, Interpretive Guidelines, training presentations, and in other
less formal venues. This memo attempts to consolidate and clarify them
for the surveyor's use and understanding. |
State Survey Agency Directors |
|
10-08 |
Phasing Implementation of Life Safety Code Surveys in
ESRD Facilities for CY 2010 |
LSC surveys are being phased into the ESRD survey
program in two phases. Phase I includes the implementation of initial
surveys for new facilities, relocation surveys for existing facilities
which move to a new location, and complaint surveys that include allegations related to LSC requirements. LSC surveys for
existing ESRD facilities will be implemented following the development
of Interpretive Guidance specific to those surveys, an ESRD LSC Survey
Protocol, and a specific Training Module for ESRD LSC. |
State Survey Agency Directors |
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10-09 |
Revised Hospital Anesthesia Services Interpretive
Guidelines SOM Appendix A |
CMS is clarifying the interpretive guidelines
concerning the provision of anesthesia services in a hospital. |
State Survey Agency Directors |
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Content contact: Gina Bertolini
E-Mail: Gina.Bertolini@dhs.wisconsin.gov
Phone: (608) 266-6691
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Last Updated: July 03, 2012
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