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DQA Quarterly
Information Update

January 2011

PDF Version of this month's Quarterly Update (PDF, 397 KB)





New Director of DQA Office of Plan Review and Inspection

In the July 2010 DQA Quarterly Update, it was announced that the Wisconsin Department of Administration had approved the Department of Health Services' request to reorganize the Division of Quality Assurance. The reorganization created the Office of Plan Review and Inspection (OPRI) and moved DQA's Civil Engineer Advanced and support staff positions from the Bureaus of Health Services and Nursing Home Resident Care to OPRI.

We are pleased to announce the appointment of David Soens as Director of the Office of Plan Review and Inspection effective December 12, 2010. David has a long history of experience working in the health care construction and design industry as both a licensed professional engineer and as a registered architect. He has over nine years of experience working as DQA's lead consultant engineer, serving as the Department of Health Services fire marshal. Most recently, David served as program director with the University of Wisconsin responsible for technical education for engineers and architects.

David is affiliated with numerous professional associations including the National Fire Protection Association, the American Institute of Architects, the Wisconsin Healthcare Engineering Association, and the International Code Council.

David holds Bachelor's and Master's degrees in mechanical engineering and a Master of Architecture degree from the University of Wisconsin. He will be headquartered in the Madison Central Office. Please join us in welcoming David to his new position.

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Authorized Allied Health Members and Ordering Hospital Physical Therapy Services
Bureau of Health Services

"Can a doctorate-prepared physical therapist be considered an "authorized allied health member" and order physical therapy services in a hospital?"

DHS 124.21, Wis. Admin. Code, addresses rehabilitation services in hospitals and provides in pertinent part:

(4) ORDERS. Physical therapy, occupational therapy, speech therapy and audiology services shall be given in accordance with orders of a physician, a podiatrist or any allied health staff member who is authorized by the medical staff to order the service. The orders shall be incorporated into the patient's medical record.

DHS 124.02(1), Wis. Admin. Code, defines "allied health personnel" as:

Persons who are not physicians, podiatrists or dentists but who are admitted to practice in the hospital through the medical staff credentialing process or are hospital employees who function under the supervision of physicians, podiatrists or dentists as stated in the appropriate job descriptions.

According to the above definitions, if the therapist is authorized by hospital medical staff to order the service and if the therapist is either admitted to practice in the hospital through the medical staff credentialing process or functions as a hospital employee under the supervision of physicians, podiatrists or dentists (as stated in the appropriate job descriptions), the therapist qualifies as an allied health personnel within the meaning of DHS 124.21, Wis. Admin. Code.

However, the scope of practice of a physical therapist falls within the purview of the Wisconsin Department of Regulation and Licensing and the Physical Therapy Examining Board. Chapter 448.56, Wis. Stats., and PT 6.01, Wis. Admin. Code, allows a physical therapist to practice without referral only under specified conditions:

  • The physical therapist provides services to an individual for a previously diagnosed medical condition (after informing the individual's physician, chiropractor, dentist, podiatrist, or advanced practice nurse prescriber who made the diagnosis);
  • The physical therapist provides conditioning services;
  • The physical therapist provides services related to injury prevention and application of biomechanics; or
  • The physical therapist provides treatment of musculoskeletal injuries, except for treatment of acute fractures or soft tissue avulsions.

As an allied health personnel, a physical therapist is restricted from independently ordering his or her own services other than ordering services that fall within the areas set forth immediately above.

In addition, it should be noted that a physical therapist cannot issue an order for the admission of a patient to a hospital per DHS 124.05(2)(g)1, Wis. Admin. Code. Furthermore, per 42 CFR 482.12(c)(1) and (2), every Medicare hospital patient must be under the care of a physician, dentist, podiatrist, optometrist, chiropractor or clinical psychiatrist and be admitted to the hospital by a practitioner authorized to admit by state law.

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Mail with Insufficient Postage

Recently, the Division of Quality Assurance (DQA) has been receiving increasing amounts of mail with insufficient postage. DQA would like to remind all entities that send mail to any of our DQA offices to ensure sufficient postage is provided when mailing. Any mail received by DQA with postage due will be returned to the sender.

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Assisted Living Administrator's Training
Bureau of Assisted Living

The qualification requirements for administrators of community-based residential facilities (CBRFs) are found in DHS 83, Wis. Admin. Code. An administrator must have one of the five qualifications listed in DHS 83.15(1)(a)-(e).

Under DHS 83.15(1)(c), an individual with a bachelor's degree in a non-health care related field from an accredited college may qualify as an administrator if that individual has successfully completed a department-approved assisted living administrator's training course.

Additionally, under DHS 83.15(1)(d), an individual with at least two years experience in a health care related field having direct contact with one or more of the client groups identified under DHS 83.02(16) may also qualify if that individual has successfully completed the aforementioned course.

On December 1, 2010, the department issued its first approval of an assisted living administrator's training course. Direct contact information for that course is available on the Bureau of Assisted Living website at the following link:

The Bureau of Assisted Living will continue to provide information as other approved courses become available.

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CBRF Department-Approved Training: Second Quarter Reports
Bureau of Assisted Living

As part of the DHS inter-agency agreement with UW Oshkosh, quarterly reports are produced showing the number of approved instructors on the registry, the number of students on the registry, the number of classes conducted, and scatter maps of instructor locations. A PowerPoint and maps summarizing this information can be found at the following link:

As part of the Quality Improvement process, Kevin Coughlin, Director of the Bureau of Assisted Living, and UW Oshkosh staff meet regularly. Some of the improvements made in the second quarter include UW Oshkosh hiring of a part-time person to improve data entry; enhanced reports showing how an instructor was qualified; and, the posting of instructor renewal information on the instructor webpage.

Since the April 1, 2010, start of CBRF department-approved training requirements, 13,751 students have participated in 2,830 classes. In addition, there are 1,134 approved instructors and six approved Train the Trainer (TtT) programs in the three topic areas. DQA and UW Oshkosh continue to provide data to approved instructors in order to help fill the gaps in geographic areas where more instructors are needed and to highlight the need for more Train the Trainer (TtT) programs. Approved Train the Trainer (TtT) programs can be found at the following link: 

Additional Information Regarding CBRF Instructor Renewals

The first CBRF Instructor renewals will not be due until early 2012. Some instructors will need to make a considerable time investment in order to qualify for renewal of their CBRF Instructor Approval. Therefore, UW Oshkosh has notified current instructors of many requirements, even though all of the requirements have not been established at this time. As more information becomes available it will be posted on the CBRF Registry and Training website, on the Instructor page and the FAQ page found at:

UW Oshkosh has sent informational e-mails to instructors approved as of November 30, 2010, or earlier. The next set of renewal information e-mails will be sent after April 1, 2011 for instructors approved between December 1, 2010 and March 31, 2011. Subsequent e-mails will be sent to newly approved instructors on a quarterly basis.

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CMS Required Sprinkler Status by August 13, 2013 - LTC Facilities

On August 13, 2008, CMS published a final rule that requires all long-term care facilities to be equipped with a complete, supervised automatic sprinkler system by no later than August 13, 2013. Facilities with no or partial sprinkler systems installed and/or that use waivers or the Fire Safety Evaluation System (FSES) to comply with the current sprinkler requirements have until August 13, 2013 to install or upgrade the sprinkler system.

Please review your facility's sprinkler system to ensure it fully complies with the National Fire Protection Association's (NFPA) "Standard for the Installation of Sprinkler Systems" (1999 Edition, NFPA 13). The Federal survey process requires review of the sprinkler system to determine if the system is providing complete coverage or only partial coverage.

Complete coverage means that the entire facility, including all closets, storage areas, and walk-in coolers and freezers, are sprinkler protected. There are specific requirements for overhangs attached to the outside of the building (1999 Edition, NFPA 13, Section 5-13.8), electrical equipment rooms (1999 Edition, NFPA 13, Section 5-13.11), and Elevator Hoistways and Machine Rooms (1999 Edition, NFPA 13, Section 5-13.6) that are the responsibility of the facility to understand and comply with and that may result in costly upgrades that will require time to complete.

Since there is no waiver and/or FSES provision after August 13, 2013, it is imperative that you ensure that your facility is fully sprinkled in accordance with the regulation on August 13, 2013. Failure to do so is likely to result in enforcement remedies, up to and including, termination.

If you have any questions regarding the sprinkler status requirements, please contact Daniel Kristola, LSC Principal Program Representative in the CMS Chicago regional office at 312-886-5210.

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Nurse Aide Training - Waiver of Federal Prohibitions
Office of Caregiver Quality

A skilled nursing facility can be placed under a 2-year prohibition for training nurse aides, if the facility has:

  • been subject to an extended or partial extended survey under federal regulations;
  • been subject to a federal civil money penalty of not less than $5,000;
  • been subject to the penalty of denial of payment under Title 18 or Title 19;
  • a waiver of the requirement for a full time registered nurse employed 40 hours a week;
  • a waiver of the requirement for a registered nurse for at least 8 consecutive hours, 7 days a week;
  • been terminated as a provider under Title 18 (Medicare) or under the State plan under Title 19 (Medicaid);
  • been subject to the penalty of an appointment of a temporary manager to oversee operations; or
  • been closed or had its residents transferred due to State action.

A skilled nursing facility that is under a 2-year prohibition may request a waiver to continue to serve as a clinical site during this time period. In order to apply for a waiver the following conditions must be met:

  • There is no approved training program within a 45-mile or 60-minute radius from the facility requesting the waiver;
  • The facility is an adequate training environment because the prohibitions were nonresident/nursing care related;
  • An approved training program unrelated to the facility has agreed to provide the training; and,
  • The applicant has alerted the ombudsman of its waiver request.

After the Statement of Deficiency has been served and the Plan of Correction has been implemented, a waiver request may be submitted by the skilled nursing facility in writing and sent to OCQ specifying how the criteria are met. OCQ will approve or deny each waiver request in writing within 45 days of receipt. OCQ may modify the terms of a waiver request, impose other conditions or limit the duration of the waiver that is approved. Submit waiver requests to:

Nurse Aide Training Consultant
Office of Caregiver Quality
P.O. Box 2969
Madison, WI 53701-2969

Questions? Contact the DQA Office of Caregiver Quality at:

Telephone: (608) 261-8319
Fax: (608) 264-6340

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Medication Administration in Hospitals:  "30 Minute Rule"
Bureau of Technology, Licensing and Education

Over the past few months the Institute of Safe Medication Practices (ISMP) reported on a CMS rule requiring medications to be administered within 30 minutes of the assigned time. Subsequently, ISMP surveyed nurses who shared multiple stories as to how the 30 minute rule is actually causing more problems and unsafe practices. The articles can be read at:

Although the 30 minute rule and subsequent concerns as described in the ISMP articles were not thought to be an issue in Wisconsin, DQA convened a conference call with representative hospitals, the Wisconsin Hospital Association, and two nursing schools. The purpose of the teleconference was to discuss concerns and issues presented in the ISMP article and its survey of nurses to insure problems are not occurring and will not occur in the State of Wisconsin.

The 30 minute rule defined in Nursing Standards of Practice and CMS interpretative Guidance is not a regulation. The 30 minute rule is a nursing standard of practice that is taught in nursing schools. The 30 minute rule is also a CMS probe in the interpretive guidance of the Acute Care Hospital State Operations Manual and, as such, serves as one example of items surveyors ask hospital staff when evaluating the medication administration system. To determine if medications are being administered appropriately, a surveyor must look at the medication, the condition of the patient, and facility policies.

Many medications may be assigned an administration time, but clinically many of these medications do not need to be administered at that specific time or within 30 minutes; administration time would not alter the patient's outcome or medical condition. As is current survey practice, when a surveyor reviews medication administration and concerns are identified, additional information is obtained about the patient, the medication and the facility procedures to determine if a problem exists. There are other evidence-based medication administration standards of practice that can be used, if appropriate to the population the facility serves.

The participants in the conference call and DQA are extremely concerned about nurses engaging in unsafe practices and committing actual medication errors that were identified in the ISMP survey. DQA wishes to inform providers that, if unsafe practices are leading to medication errors, those issues will be reviewed in the survey process including a review of the hospitals quality assurance programs incorporation of the medication safety concerns.

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Changes in DQA Staff

David Soens
Director, Office of Plan Review and Inspection (See page 1.)

Fokruddin Khondaker
Engineer, Office of Plan Review and Inspection

Fokruddin comes to DQA from the Department of Commerce and has several years of working in both industry and government and has a much-needed background in IBC and plan review. He will primarily work with hospitals in the southeastern region, but will also be trained in other provider types.

Sharon Paulson
Health Service Specialist, Bureau of Assisted Living (SRO)

Sharon Paulson has accepted the Health Service Specialist position and will begin January 24, 2011. Sharon is a Certified Social Worker, holds a Nursing Home Administrator license, and has worked in both the assisted living and nursing home industry for the past 28 years.

Moua Luedtke
Licensing Permit / Program Assistant, Bureau of Assisted Living (WRO)

Moua Luedtke accepted the Licensing Permit / Program Assistant position in the Western Regional Office and will be starting Jan. 31.

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DQA Numbered Memos (October, November, December)

Access these memos via or via individual providers' publications pages at

Memo No.



Providers Affected


U.S. Department of Labor - Employment of Youth in the Health Care Industry

The purpose of this memo is to share a recent U.S. Department of Labor interpretation of The Fair Labor Standards Act (FLSA) which impacts youth under the age of 18 working in the health care industry. DQA does not have regulatory authority to enforce these child labor standards but wants to ensure that healthcare settings regulated by DQA are aware of them.

This memo contains important information and guidance on the following topics --- U.S. Department of Labor Interpretation, Impact on Nurse Aide Training Programs, Follow-up.

Licensed Adult Family Homes, Certified Mental Health and AODA Programs, Community Based Residential Facilities, Facilities for the Developmentally Disabled, Home Health Agencies, Hospices, Hospitals, Nurse Aide Training Programs, Nursing Homes, Personal Care Providers, Residential Care Apartment Complexes


Revised Resident Relocation Manual

DHS has revised and updated its Wisconsin Statutes, Chapter 50, Resident Relocation Manual. The draft revised manual was released in March, 2010. Following a 6 month comment period that ended on September 15, 2010, the final revised manual has now been published. Residential facilities considering relocation of 5 or more residents are strongly encouraged to contact the Division of Long Term Care as soon as possible in their decision making process for consultation regarding Ch. 50 requirements.

CBRFs, FDDs, Nursing Homes, ADRC Directors
BOALTC Executive Director, Disability Rights Wisconsin Executive Director, County Department of Human Service Directors, County Department of Social Services Directors, County Departments of Community Program Directors, County/Tribal Aging Unit Directors, MCO Chief Executive Officers, IRIS Program Managers


Email Encryption

The Department of Health Services (DHS) has implemented an e-mail encryption solution designed to protect e-mails sent to recipients outside of the state e-mail network.

Ambulatory Surgery Centers, Adult Day Care Centers, Adult Family Homes, Certified MH 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


Residents' Right to Transfer and Discharge Protections

This memo reinforces the concept that residents have rights and protections when going through a transfer or discharge process. The resident, the resident's physician and, if known, an immediate family member or legal counsel, guardian, relative or other responsible person must be provided with written notice whenever discharge from the facility is decided regardless of whether it's voluntary or involuntary in nature or who initiates the discharge. Once a facility notifies a resident of an involuntary discharge, the resident has the right to appeal. Residents also have the right to be represented by counsel.

Nursing Homes


Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities

In recent years there has been increased awareness of the impact of Norovirus as the primary cause of gastroenteritis outbreaks in nursing homes and assisted living facilities.
At the request of the Wisconsin Division of Public Health, Bureau of Communicable Diseases, the DQA is reissuing the DPH Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities. These recommendations were initially released on January 12, 2009 via the DHS-DQA publications list serve.

Adult Day Care, Adult Family Homes, Community Based Residential Facilities, Facilities Serving People with Developmental Disabilities, Nursing Homes, Residential Care
Apartment Complexes


Waivers of DHS Ch. 83 Provisions Granted Prior to April 1, 2009

The purpose of this memo is to address the variances and waivers that were issued prior to the repeal and recreation of Wisconsin Administrative Code chapter DHS 83, Regulating Community-Based Residential Facilities (CBRFs).

Community Based Residential Facilities


Personal Care Provider Program Update Complaint Investigations

The purpose of this memo is to provide information about complaint investigations conducted in Medicaid certified personal care providers by the Department of Health Services.

Area Administrators / HS Area Coordinators, Area Agencies on Aging, Community Alliance of Providers of Wisconsin, County Aging Units / Directors,
County COP Coordinators, County DCP Directors, County DDDS Directors, County DHS Directors, County DSS Directors, County Waiver Coordinators, County DD Coordinators, ILCs, Personal Care Providers, Residential Services Association of Wisconsin, Tribal Chairpersons, Wisconsin County HS Association, Wisconsin Personal Services Association


Mandatory Reporting of Influenza-Associated Hospitalizations

The purpose of this memo is to introduce a Division of Public Health memorandum which states, "…effective December 1, 2010 Influenza-associated hospitalizations to be reported within 72 hours of identification (Category 2) to local public health agencies."



Informed Consent for Psychotropic Medications

The purpose of this memo is to inform nursing homes regulated by the DQA about the new requirements for informed consents for psychotropic medications.

Nursing Homes


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DHS Administrative Rules Update
Administrator's Office

DQA Omnibus Rule (located within DHS 12)
DHS 12 - Caregiver Background Checks
DHS 83 - Community-Based Residential Facilities
DHS 88 - Adult Family Homes
DHS 124 - Hospitals
DHS 127 - Rural Medical Centers
DHS 148 - Cancer and Chronic Disease Drug Repository Program
DHS 165 - Laboratory Certification

On January 1, 2011, the DQA Omnibus Rule went into effect. The Omnibus Rule makes a number of changes, primarily of a minor and technical nature, to the above identified rules to update, correct, or remove outdated rule provisions and cross-references. The revised rules can be viewed on the Wisconsin Administrative Rules website at the following link:

DHS 124 - Hospitals

During the early part of 2008, the Department of Health Services began working with hospitals, professional associations, advocates, and trade associations to revise Wisconsin Administrative Code, Chapter DHS 124, Hospitals. Active work on DHS 124 is not currently underway. The Department will resume work on this rule in the future. A Statement of Scope is posted on the Wisconsin Administrative Rules website and can be viewed at the following link:

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CMS Survey & Certification Letters (October, November, December)

S&C No.



Providers Affected


Advance Copy: Revisions to Appendix PP, State Operations Manual, Guidance to Surveyors for Long Term Care Facilities for Minimum Data Set 3.0 Implementation October 1, 2010

This memo provides Guidance to Surveyors, Effective Date of the Revisions to Appendix PP of the SOM, Training Materials.

Nursing Homes, State Survey Agencies


Copy of Chapter 7 - Survey and Enforcement Processes for Skilled Nursing Facilities and Nursing Facilities

The purpose of this memorandum is to provide State survey agencies and CMS regional offices a copy of Chapter 7 of the State Operations Manual (Pub. 100-07).

Nursing Homes, State Survey Agencies


Impact of Submission Issues with the Minimum Submission and Processing (ASAP) System on the Long-term Care (LTC) Survey Processes

Guidance to Surveyors- This memorandum outlines the handling of LTC facility citations at F287 regarding MDS submissions as a result of an issue with the CMS MDS 3.0 ASAP system.

Nursing Homes, State Survey Agencies


Survey and Certification of Chemical Toxicity Public Health Laboratories (CT PHL';s) under the Clinical Laboratory Improvement Amendments (CLIA)

To facilitate preparedness in the event of a chemical terrorism act, all designated CT PHL';s will request and obtain a CLIA certificate at their projected highest level of testing, regardless if testing human samples presently.

CLIA Laboratories


FY 2011 Inpatient Prospective Payment System (IPPS) Rule Changes Affecting Survey and Certification

The final FY 2011 IPPS rule was published on August 16, 2010 (75 FR 50042) and was effective on October 1, 2010. Several provisions in the rule directly affect areas of survey and certification responsibility. There were also changes in the Medicaid rules that are of interest because of their connection to the Hospital CoPs as well as CMS-approved national hospital accreditation programs.


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


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Last Updated: September 30, 2011