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Wisconsin Department of Health Services

DQA Quarterly
Information Update

January 2012

PDF Version of this month's Quarterly Update (PDF, 233 KB)





Hospitals: Change in Contact Information for Mandatory Reporting
Bureau of Health Services

There is a change of the fax number and e-mail address for mandatory reporting of restraint and seclusion deaths by hospitals, effective September 16, 2011. 

Fax: (443) 380-8952 

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New Caregiver Investigation Unit Office of Caregiver Quality
Office of Caregiver Quality

There is now a newly formed Caregiver Investigation Unit in the DQA Office of Caregiver Quality (OCQ). The OCQ Investigation Unit is comprised of Consumer Protection Investigator (CPI) 3 staff --- Randy Busch, Katie Czys, Faye Krebs, Janelle Paske, and Josh Pulver; and, one Investigation Supervisor, Nora Mendoza.

Randy comes to OCQ from the Department of Veterans Affairs and is also employed as a boat patrol officer; Katie has been employed as a law enforcement officer and is also employed as an EMT; Faye has been an intake and field investigator in OCQ and previously worked at the former Department of Regulation and Licensing; Janelle most recently worked as an investigator with the Department of Transportation (DOT); and, Josh was employed as a CPI at the Department of Safety and Professional Services (DSPS).

All five individuals have knowledge of criminal and/or administrative investigations, as well as the critical skills needed to complete a good investigation. They all have experience conducting interviews, examining healthcare records, collecting relevant documentation, and preparing accurate and detailed investigative reports.

Nora comes to OCQ from the DQA Bureau of Assisted Living. She has previous work experience as a supervisor and as a Quality Assurance Program Specialist, so has knowledge of supervisory techniques, is familiar with the Caregiver Law requirements, has conducted onsite inspections, and has investigated complaints.

Contact Nora Mendoza if you have any questions about the unit, if you need to verify receipt of any complaints, or to check on the status of any misconduct cases. Nora Mendoza (608) 261-8395

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Wisconsin Clinical Resource Center (WCRC): New and Improved Website

It's the time of year to visit the new and always improving Wisconsin Clinical Resource Center (WCRC) website at: Recently, the WCRC website has gone through many changes and now has a whole new look for the New Year. It still has all the great information found there in the past, all pulled together in an easy to navigate, user-friendly way. Some of the new highlights include: 

  • An updated website design 
  • A new Module on Transitions in Care 
  • Updated AMDA Clinical Practice Guidelines

All this information is available on the website and is easy to find and use. If you aren't sure of your WCRC logon information, check with your administrator to find out your facility username and password or call your member association for more information.

The Wisconsin Clinical Resource Center (WCRC) project is jointly sponsored by LeadingAge Wisconsin and Wisconsin Health Care Association (WHCA/WiCAL) through funding from the Wisconsin Department of Health Services. Development support is provided by staff from the Center for Health Systems Research and Analysis (CHSRA), UW-Madison. The WCRC website was designed as a user-friendly resource to provide key information about selected care areas and training programs.

In addition, access to the updated American Medical Directors Association (AMDA) Clinical Practice Guidelines is provided free of charge. The care area and training content includes input and recommendations from a diverse group of professionals working in long-term care, including staff and consultants working in Wisconsin nursing homes. The selected care area modules include: Dehydration, Dementia, Depression, Diabetes, Falls, Infections, Nutrition, Pain Management, Pressure Ulcers, Restraints, Transitions in Care, and Urinary Incontinence. There are also five companion training programs available. WCRC Website Address: For more information, contact your member association or contact the WCRC helpdesk at:

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Name Changes: American Dietetic Association and Dietary Managers Association
 Bureau of Technology, Licensing and Education 

  • The American Dietetic Association, the world's largest organization of food and nutrition professionals, has changed its name to Academy of Nutrition and Dietetics (AND), effective January, 2012. ADA (now AND) is committed to improving the nation's health and advancing the profession of dietetics through research, education and advocacy. For more information, visit:

  • The Dietary Managers Association has voted to change its name to Association of Nutrition and Foodservice Professionals effective January 1, 2012. For more information, visit:

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FDA: "Preventing Surgical Fires Initiative"
Bureau of Technology, Licensing and Education

The Food and Drug Administration (FDA) and its partners have launched a "Preventing Surgical Fires" initiative to: 

  • Increase awareness of factors that contribute to surgical fires
  • Disseminate surgical fire prevention tools
  • Promote the adoption of risk reduction practices throughout the healthcare community

The FDA's recommendations to reduce the risk of surgical fires can be accessed at:

Additional resources can be accessed at:

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New Licensing and Permitting Requirements: Medical Radiography and Providers of Medical Radiographic Services
 Bureau of Technology, Licensing and Education

In 2010, a new law was enacted in Wisconsin which established licensing and permitting requirements for those who perform medical radiography or who provide medical radiographic services. The new law, 2009 Wisconsin Act 106, which created Chapter 462 of the Wisconsin statutes, requires that any person who performs radiography or operates an X-ray machine or X-ray equipment and is not exempt from the law, shall obtain a license to perform radiography or a permit to operate X-ray machines or perform limited scope radiographic procedures.

The Department of Safety and Professional Services Radiography Examining Board issued an advisory bulletin to inform all persons who are affected by the new law about the options for obtaining the license or permit, the requirements and qualifications required for each, and to briefly explain the application process. Facilities that have individuals performing radiography or operating x-ray equipment should review the new requirements and make sure that staff is in compliance or is exempt. Additional information can be accessed at:

Attention: Ambulatory Surgical Centers, Hospitals, Rural Health Clinics. Facilities should ensure that staff who perform these services meet the requirements for license or permit or meet the exemptions. Specific criteria can be accessed at the above link.

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Glucose Meters and Waived Laboratory Testing
 Bureau of Technology, Licensing and Education and Bureau of Health Services

In November 2011, DQA released Memo 11-031, "Glucose Meters and Infection Control." In addition to that memo, the Bureau of Health Services Clinical Laboratory Section is announcing that they will soon start the annual Certificate of Waiver project where the section visits a small percentage of facilities performing waived laboratory testing, which includes blood sugar testing with glucose meters. This is part of the federal project, in conjunction with CMS and the CDC, to increase the awareness of waived laboratory testing and to provide technical assistance in understanding and following manufacturer's instructions.

CMS and CDC have collaborated on this project since 2002 and have recently introduced both training tools and materials for assisting facilities conducting waived laboratory testing. One of the tools is an on-line course which anyone can take. The web-site is located at:

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Certification Proposal for Mental Health Professionals with Individual Provider Status
 Bureau of Health Services / Behavioral Health Certification Section

The Department of Health Services, Division of Quality Assurance, Behavioral Health Certification Section (BHCS) and the Bureau of Prevention, Treatment and Recovery (BPTR) have participated in a series of meetings with the Joint Board of Marriage and Family Therapy, Professional Counseling and Social Work (MPSW), and Department of Safety and Professional Services (DSPS) staff regarding credentialing options for mental health practitioners currently providing psychotherapy, the result of confirmation of training and clinical experience via the Individual Provider Status Application process.

Chapter DHS 35.03 (10) defines the "Mental Health Practitioner" as a "person who before January 1, 2012, holds a graduate degree from an accredited college or university in psychology, counseling, marriage and family therapy, social work, nursing, or closely related field, and either has completed the applicable supervised practice requirements under ch. MPSW 4, 12, or 16, or Psy 2 or has 3,000 hours of supervised clinical post-graduate degree experience, including at least 1,000 hours of face-to-face contact with consumers, and who commences work at a clinic required to be certified under this chapter no later than January 1, 2013." Professionals meeting these requirements may continue to provide psychotherapy in State certified clinics.

The proposal being considered by DSPS and DHS representatives is to develop a level of "certification" for those mental health professionals with Individual Provider Status approval that would permit future movement into one of the MPSW licensure paths. The purpose of the proposed certification is to ensure that, in the future, such individuals are required to complete continuing education requirements similar to those of licensed mental health professionals and to provide DSPS the authority to discipline such an individual for violations of unprofessional conduct.

DSPS and DHS staff would appreciate your assistance in determining how many professionals practice psychotherapy in your certified clinic using only the Individual Provider Status confirmation letter from BHCS. This information will help determine the number of practitioners providing psychotherapy services and help provide important updates regarding the transition process. To avail yourself of this opportunity, please complete the short survey at the following link:

Contact Information:

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Update: Revision of BHCS Applications
 Bureau of Health Services / Behavioral Health Certification Section

Substantial progress has been made to update and create electronic application forms for mental health and substance abuse treatment programs/services. These updated forms are available for review at the following link: Currently, BHCS does not accept these forms electronically, but the form revisions and the ability to fill them out electronically will help expedite the application processes. Questions about application information should be forwarded to:

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MDS Section Q Referrals - Automation Early 2012
 Bureau of Health Services

The Department of Health Services has been working on a system to automate referrals to local contact agencies under MDS 3.0, Section Q. The system development is nearing completion and DHS expects the system to be available for use early in 2012. Nursing homes will receive additional information in a numbered memo from the Division of Quality Assurance. Training on the new system will be available on-line for use by nursing homes and the local contact agencies.

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Important Changes within Behavioral Health Certification Section
Bureau of Health Services / Behavioral Health Certification Section

BHCS has undergone tremendous change in the past year. Retirements of Frank Bellaire (Northeast Region), Mark Isaacs (Southeast Region), Rick Ruecking (Southern Region), and Mary "Bid" Webb (Central Office) have resulted in multiple business challenges, including "triaging" of certification and investigatory assignments.

Cindy Lindgren reinstated as a Health Services Specialist and has been completing reviews in multiple regions. In January 2011, Bradley Jahr replaced Steve Ojibway (Northern Region) who passed away July 30, 2010. Sally Andrews was recently selected to replace Bid Webb and she is currently engaged in an orientation process under Bid Webb's tutelage.

Program/service providers are now directed to send all initial application or recertification materials to BHCS Central Office for processing, rather than sending these materials and payment to the regional offices. Inquiries about these changes should be directed to: or

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End Stage Renal Dialysis Provider Forum
 Bureau of Health Services 

The Division of Quality Assurance has developed a provider forum for end stage renal dialysis providers. The first forum is scheduled for: 

     Thursday, March 1, 2012
     1:00 p.m. - 3:00 p.m.
     1 West Wilson St., Room 950A
     Madison, WI

It will also be available by ADOBE ConnectPro. If you wish to attend this forum via ADOBE ConnectPro or in person, call (608) 266-0297; ask to be placed on the invitation list and indicate how you wish to attend.

The forum is an opportunity to receive information regarding the federal regulations governing end stage renal dialysis providers and the survey process. Future forums will cover topics solicited from participants.

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Changes in DQA Staff

Behavioral Health Certification Section - Retirements
Bureau of Health Services / Behavioral Health Certification Section 

Frank Bellaire (NERO)
Mark Issacs (SERO)
Rick Ruecking (SRO)
Mary "Bid" Webb (Central Office)

Susan Murphy- Retirement
RFOD / Bureau of Assisted Living (WRO)

Susan Murphy, Regional Field Office Director of the Bureau of Assisted Living Western Regional Office, retired December 2, 2011, after 37 years of outstanding public service. Susan was a member of the original team when BAL first became a Section. Her leadership and hard work lead to a number of innovative initiatives that have helped BAL become an effective and efficient regulatory agency receiving national acclaim.

Dolores Zwiers - Retirement
RFOS / Bureau of Nursing Home Resident Care (NERO)

Dolores Zwiers, Regional Field Office Supervisor in the Northeastern Regional Office, retired December 2, 2011. Dolores was a long time employee of DQA and was passionate about her work and truly believed that she was having a positive impact on the lives of our senior citizens. She led the BNHRC / NERO as a RFOD and as a RFOS.

Lean Smart - New Employee
Health Service Specialist / Bureau of Assisted Living (NERO)

Lean Smart has accepted the Health Service Specialist position and will began January 3, 2012. Lean has a M.S. in Educational Psychology, a B.S. in Interdisciplinary Studies with Emphasis in Human Development, and has served four years in the United States Air Force as an Aerospace Medical Service Journeyman. Lean has experience working with persons with mental illness and AODA- specific issues, providing individual and group counseling, developing treatment plans, and conducting assessments. 

Trudy Ciszek - New Employee
Nurse Consultant / Bureau of Technology, Licensing and Education (Central Office)

Trudy is the new nurse consultant for home health, hospice, and personal care agencies (position formerly held by Marianne Missfeldt). Trudy may be contacted at: 608-266-7881 or

Sally Andrews - New Employee
Licensing and Permitting Specialist / Behavioral Health Certification Section (Central Office)

Sally Andrews was recently selected to replace Bid Webb and is currently engaged in her orientation process.

Josh Wall - New Employee
Quality Assurance Program Specialist / Office of Caregiver Quality

Josh wall has been hired as the Quality Assurance Program Specialist (QAPS) - Senior in the Office of Caregiver Quality (OCQ). Josh comes to OCQ from Dane County Human Services where he was employed as an Overpayment Specialist. He has previous experience as an Economic Support Specialist and as a Deputy Sheriff and Jail Clerk with the Dane County Sheriff's Office. As the QAPS in OCQ, Josh will work closely with both the nurse aide training and caregiver misconduct functions.

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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


Resident Hand Hygiene in Nursing Homes

The purpose of this memo is to provide nursing homes with information regarding their role and responsibilities related to resident hand hygiene.

Nursing Homes

11-026 Using Social Media Platforms, such as Twitter, Facebook, MySpace and LinkedIn This memorandum provides guidance to providers on the fast-changing landscape of the internet and the impact of using social networking and social media as a communications tool. Adult Family Homes
Community Based Residential Facilities
Certified Mental Health and AODA Programs
Facilities for the Developmentally Disabled
Home Health Agency
Nursing Homes
Residential Care Apartment Complexes
11-027 Construction Requirements for New 'Class-C' CBRF Structures The purpose of this memorandum is to provide information on the Department's position regarding the physical plant requirements for new community-based residential facility (CBRF) licensure, as these requirements relate to the application of the Wisconsin Commercial Building Code (WCBC). Community Based Residential Facilities
11-028 Submission of Construction Plans to the Madison State Office Building The purpose of this memo is to inform design firms and health care facilities, for a temporary period, that they will need to direct all construction plans for Division review to the Madison Central Office address. The temporary change, which takes effect immediately, affects healthcare facilities located in the Eastern part of Wisconsin. Ambulatory Surgical Centers
Community Based Residential Facilities
End Stage Renal Dialysis
Nursing Homes
11-029 Fees for Copies of Health Care Provider Records Effective July 1, 2011 Effective July 1, 2011, 2011 Wisconsin Act 32 (Budget Bill) amended the fees a health care provider is authorized to charge for copies of health care records. Adult Family Homes
Community Based Residential Facilities
Facilities for the Developmentally Disabled
Nursing Homes
Rural Medical Centers
11-030 Adult Family Home Training Requirements The purpose of this memorandum is to identify the training requirements for adult family home service providers and licensees and describe the sources of training that are acceptable to the Department. Adult Family Homes
11-031 Glucose Meters and Infection Control This memo is a reminder to facilities to evaluate the products and procedures that are being used to clean and disinfect glucose meters to ensure that they are effective against blood-borne pathogens. Nursing Homes
11-032 Guidance for Investigating and Reporting Alleged Violations in Nursing Homes The purpose of this memo is to clarify what constitutes a reportable alleged violation, including a violation of resident-to-resident abuse, that should be reported to the DQA Office of Caregiver Quality. Nursing Homes
11-033 Guidance for F371 This memo provides guidance for F371, Sanitary Conditions, regarding food-borne illnesses. Nursing Homes
11-034 Wisconsin Statutes, Chapter 50, Revisions Relating to State Violations, Appeal Provisions, Forfeitures and Enforcement Action The purpose of this memo is to provide information to providers regarding the effect this law has on providers. Facilities for the Developmentally Disabled
Nursing Homes

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DHS Administrative Rule and Wisconsin Statute Updates
Administrator's Office

Wisconsin Statutes, Chapter 50, Revisions Relating to Nursing Homes

State Violations, Appeal Provisions, and Enforcement Action
On November 16, 2011, Governor Walker signed 2011 Wisconsin Act 70 into law, effective December 2, 2011. The new law makes changes to Wisconsin Statutes affecting the regulation of nursing homes, including facilities serving people with developmental disabilities. Certain provisions in the law apply only to federally certified nursing homes; other provisions apply to all nursing homes and to facilities serving people with developmental disabilities. 

Federally Certified Nursing Homes Only
Section 50.04(4)(am), Wis. Stats., outlines provisions pertaining to dual citations of federal and state violations in federally certified nursing homes. Under the new law, the Department of Health Services (DHS) / Division of Quality Assurance (DQA) is prohibited from issuing a state violation if the Department has served a federal deficiency for the same facts. This section of the law does not pertain to facilities serving people with developmental disabilities or to nursing homes that are not federally certified. 

2011 Wisconsin Act 70 amends several sections of the statute to allow DHS to use violations of federal regulations to support state licensure actions taken against nursing homes. Under the new law, DHS has the authority to consider certain violations of federal nursing home regulations in determining whether to issue a probationary or a conditional license, transfer the ownership of a facility, place a monitor in a facility, appoint a receiver, suspend admissions, suspend or revoke a license, or take over operations of a nursing home. 

Additionally, s. 50.04(8), Wis. Stats., was created and allows DHS to use federal civil money penalties (CMP) monies to fund projects that are designed to improve the quality of life, care, and treatment of nursing home residents. Similar provisions are currently available in Chapter DHS 132, Nursing Homes. Since creating the quality assurance and improvement committee in 2007, DHS has awarded hundreds of thousands of dollars to support the development of innovative care practices in nursing homes. 

All Nursing Homes and Facilities Serving People with Developmental Disabilities
Wisconsin Statutes, Chapter 50, was amended and expands the circumstances under which DHS has discretion to not cite a violation. The previous law limited the Department's discretion to self-reported violations for which the facility had made every reasonable effort to prevent and correct the violation, but the violation occurred and remained uncorrected due to circumstances beyond the facility's control. Under the new law, the Department is also not required to cite a violation if the facility brings the violation to the Department's attention and the facility has corrected the violation. 

The new law expands the amount of time allotted to contest a notice of violation or an assessed forfeiture. Nursing homes and facilities serving people with developmental disabilities now have 60 days to file an appeal of a violation or a forfeiture to the Wisconsin Division of Hearings and Appeals, instead of 10 days as previously required by law. 

The complete text of 2011 Wisconsin Act 70 can be found at:

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

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

11-40 Living Donor Services Occurring in Transplant Programs Other than that of the Organ Recipient This letter addresses Medicare requirements for transplant programs and surveyor activities in which some or all of the services for a living donor are provided by a program other than the transplant program of the organ recipient. Transplant
11-41 Affordable Care Act Section 6103: Guidance for State Consumer Oriented Websites  CMS provides a list of key elements for State website development for States to qualify for Federal funding.  Nursing Homes
RETRACTION of S&C Memo 11-37-NH CMS has retracted S&C Memo 11-37-NH Revisions to Interpretive Guidance at F tag 322, as Part of Appendix PP, so that it may incorporate instructions that pertain to the Quality Indicator Survey. Nursing Homes
12-01 Survey & Certification Focus on Patient Safety and Quality - Draft Surveyor Worksheets CMS is testing three new surveyor worksheets for assessing compliance with three hospital Conditions of Participation --- Discharge Planning, Infection Control, and Quality Assessment and Performance Improvement. A separate document containing instructions for the Infection Control worksheet is also included. Hospitals
12-02 Federal Requirements for the Independent Informal Dispute Resolution (Independent IDR) Process for Nursing Homes State survey agencies must have in place a functioning Independent IDR process with specific elements by no later than January 1, 2012. Nursing Homes
12-03 Initial Plans and Policy Implementation for Clinical and Laboratory Standards Institute (CLSI) Formal announcement of CMS' adoption of EP-23 for CLIA QC as a QC option. CLIA
12-04 Alert: Smoking Safety in Long Term Care Facilities This memo reviews current interpretive guidelines for F323, reemphasizing adequate supervision of all residents. Nursing Homes
12-05 Updated Guidance on Medication Administration, Hospital Appendix A of the State Operations Manual Revised memo updated 12/02/11. SOM Appendix A guidance concerning medication administration in hospitals is being updated to reflect current standards of practice related to timeliness of medications. Hospitals
12-06 Instructions for Completing Exhibit 286, Hospital/Critical Access Hospital (CAH) Database Worksheet Exhibit 286, the Hospital/CAH Database Worksheet, has been updated to add or refine some fields. Instructions for completing the Worksheet have also been updated, and have been added to the SOM. The ASPEN system has also been updated to correspond to the revised Worksheet. Hospitals / CAHs
12-07 Clarification of Hospital Equipment Maintenance Requirements Section 482.41(c)(2) requires that hospital facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This memorandum updates the guidance in Appendix A of the State Operations Manual related to hospital facility and medical equipment maintenance. Hospitals
12-08 Federal Requirements for the Independent Informal Dispute Resolution (Independent IDR) Process for Nursing Homes This memo replaces Survey and Certification memo S&C: 12-02-NH, dated October 14, 2011, which discusses Federal requirements for the Independent IDR process for nursing homes. Please disregard the October 14, 2011 version. Nursing Homes
12-09 Certificate and Regulatory Multiple Site Exceptions under CLIA Additional clarification and guidance is given for certifying laboratories under the various regulatory multiple sites exceptions. There are scenarios with guidance for all areas of the three regulatory exceptions for each type of certificate. CLIA
12-10 Affordable Care Act and Implications for Certification of Physician-owned Hospitals The Affordable Care Act prohibits the referral of Medicare beneficiaries by physician owners or investors to new PoHs or to existing PoHs that have expanded their facility capacity beyond their baseline (as described below). An exceptions process allows some PoHs, which meet specific criteria, to expand after the baseline date. The statutory prohibition applies to physician owner referral and hospital billing activity. It does not prohibit licensure by the States or Medicare certification by CMS of new or expanded PoHs. Hospitals / CAHs
12-11 Notice - Fifth Opportunity National Background Check Program Funding CMS released a fifth solicitation for the National Background Check Program (NBCP) for any States or U.S. Territories that were unable to meet the previous deadline for submitting their applications under the previous solicitation. Applications are due February 28, 2012. Nursing Homes
12-12 Prudent Action for the FY 2012 Medicare Survey & Certification (S&C) Budget Early indications are that the budget level for Medicare survey and certification (S&C) will most likely be 10%-12% less than the level requested by the President. Therefore, providers are encouraged to prepare now for a lower FY2012 funding level than previously expected. All


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


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Last Revised:  September 30, 2014