PDF Version of this month's
Quarterly Update (PDF, 486 KB)
NEW THIS ISSUE
New Department Name
Proposed in Governor Jim Doyle's 2007-2009 biennial budget,
and passed in November 2007 by the Wisconsin legislature, the Department of
Children and Families will be the state's first cabinet agency devoted to
promoting the economic and social well-being of children and families of the
state of Wisconsin.
As a result of this, effective July 1, 2008, the Department
of Health and Family Services (DHFS) will become the Department of
Health Services (DHS). The mission, goals and values of the Department
will remain the same.
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DQA Online and Toll Free Complaint Resources
The Division of Quality Assurance (DQA) is responsible for assuring the
safety, welfare and health of persons using health and community care
provider services in Wisconsin.
DQA receives complaints from healthcare providers and the public
regarding facility staff, regulated healthcare facilities, clinical
laboratory, and other issues.
Effective April 21st of this year, DQA is able to receive complaints via
an online process. Any person (resident, employee, ombudsman, relative,
friend, other) may file a complaint regarding any DQA regulated issues via
the DQA complaint webpage at http://www.dhs.wisconsin.gov/bqaconsumer/HealthCareComplaints.htm.
As of June 2, 2008, individuals will also be able to file a complaint
with DQA by calling the toll free telephone number 1-800-642-6552.
Both the online complaint link and the toll free number will provide
greater access to people across Wisconsin and the nation to share concerns
regarding friends or family members residing in DQA regulated facilities.
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Regional Boundary Changes for BNHRC
The current county responsibilities for certain regional offices have
changed, effective June 1, 2008. The Northern Regional Office (NRO) in
Rhinelander will be resuming responsibility for counties that had been
temporarily assigned to other regions.
The NRO will be resuming responsibility for Sawyer, Rusk, and Taylor
counties, previously the responsibility of the Western Regional Office. The
NRO will also assume responsibility for Florence, Forest, Langlade, and
Portage counties, previously under the jurisdiction of the Northeastern
Additional information regarding this change can be found in DQA Memo
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Battery Recharging of Healthcare Equipment
Electric wheelchairs, lifts, scales, and other resident/patient equipment
are becoming more prevalent in healthcare facilities each year. As a result
of reported fires occurring in electric wheelchairs while being recharged,
the Division is being more conscious of this equipment.
The primary concern is the recharging of wheelchairs within the
residents/patients sleeping room. In addition to the noted fire concern,
battery manufacturers identify hazards within their specifications. Acidic
gases or some type of byproduct are emitted from the battery while being
charged, which remain a hazard to individual's respiratory system and eyes.
The second concern is the recharging of lifts, scales, or other equipment
within an egress corridor. The means of egress in a system is not intended
for the storage or maintenance of equipment, especially when the equipment
recharging activity has an associated hazard (LSC § 18.104.22.168).
The third concern is that, with the increased presence of oxygen (both
the compressed and liquid form within healthcare facilities), the recharging
of electrical equipment can pose a source of ignition for a space or area
with higher concentrations of oxygen. Do not recharge batteries within
spaces designated as oxygen storage, transferring, or manifold room. Do not
recharge batteries within 5 feet of portable liquid oxygen systems (CGQ
Corrosion can occur on batteries and all batteries require some form
of maintenance. The facility bears the burden of providing this maintenance.
Batteries not provided the proper maintenance and cleaning will increase the
Gelled electrolyte or 'Gell-Cell' batteries are no different. These
batteries use the same electrolyte chemical process common in other
batteries using an acid, typically gelled sulfuric acid. The health hazards
associated with sulfuric acid are well known. Manufacturer claims of
producing a 'sealed battery' are quite common, yet all batteries can be
overcharged and are subject to explosion.
An enclosed equipment storage room, a hazardous storage room, an enclosed
room not used by residents/patients, i.e., an overnight physical therapy
space or a shower/tub room, may be permissible as a battery recharging
location if the following conditions are met:
- the space has continuously operating mechanical ventilation exhausted
to the outdoors;
- the room used for this recharging activity has no negative impact on
resident/patient overnight care or treatment;
- the room has properly hard wired electrical circuitry and breaker
protection (no extension cords, power taps, adapters); and
- the Division assigned Life Safety Engineer for your facility is
apprized of the situation and has no major concerns.
Some facilities have asked, "Could the attached bathroom of a
resident's sleeping room be used to recharge a wheelchair overnight?"
Typically, individual resident toileting facilities are not sized to
accommodate both the use of the bathroom and an equipment recharging
Resident access to a bathroom that is attached to their sleeping quarters
is often critical during the evening or night time hours and shall not be
compromised to accommodate equipment recharging. The removal of equipment
from a bathroom to obtain access is not conducive to a safe (fall
prevention) or a sanitary (infection control) environment.
Ventilation rates within resident/patient bathrooms are of different
types and are sometimes unreliable. If battery charging is to occur within a
space, a reliable form of ventilation is required. For instance, some
nursing homes constructed under older codes have outside windows;
unfortunately, an outside window is not a reliable source of ventilation for
a battery charging location.
Similarly, during the winter heating season or at other times when energy
costs are a concern, some facilities disconnect their exhaust fans. This is
another example of unreliable mechanical ventilation for a battery charging
Since 1985, the Division has actively encouraged facilities to set up
a secure, separate, non resident/patient, enclosed room with reliable
mechanical ventilation and proper electrical wiring in which to recharge
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CDC Launches New Patient Safety WebSite
On March 28, 2008, the CDC's National Center for Infectious Diseases,
Division of Healthcare Quality Promotion announced the availability of a new
Patient Safety Web Site that includes sections on Medication Safety and
Injection Safety. The CDC plans to further develop this site with additional
You may access this web site at http://www.cdc.gov/ncidod/dhqp/patientsafety.html.
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80 Percent Club Continues to Grow!
During the 2007-2008 influenza season, the Bureau of Communicable
Diseases and Preparedness again challenged Wisconsin hospitals and nursing
homes to vaccinate at least 80% of their employees against influenza as a
way to reduce transmission of influenza among their patients /
According to the Bureau of Communicable Diseases and Preparedness' 80%
Club, 35 hospitals and 71 nursing homes achieved the 80% employee
vaccination level, up from 19 hospitals and 45 nursing homes during the
2006-2007 influenza season. (See graph.)
(PDF, 15 KB)
The Division of Quality Assurance is pleased to recognize the following
health care organizations that have achieved this important goal.
Appleton Medical Center
Alexian Village of Milwaukee
Ashland Health and Rehab Center
Aspirus Lillian Kerr Healthcare Center
Aurora Medical Center Manitowoc County
Aurora Medical Center Oshkosh
Aurora Medical Center Sheboygan
Aurora Memorial Hospital Burlington
Baldwin Care Center
Becker Shoop Center
Belmont Nursing and Rehab Center
Birch Hill Care Center
Black River Memorial Hospital
Cedar Lake Health and Rehab Center
Childrens Hospital of Wisconsin - Fox Valley
Chippewa Manor Nursing Home
Cornell Area Care Center
Door County Nursing Home
Fair View Home
Geneva Lake Manor
Golden Living Center - Watertown
Good Samaritan Scandia Village
Grancare Inc - Fond du Lac
Grande Prairie Health and Rehab
Hayward Area Memorial Hospital
Heritage Manor - Elroy
Heritage Manor - Rice Lake
Heritage of Elmwood
Kennedy Park Medical and Rehab Center
Lakeview Medical Center
Linden Grove Menomonee Falls
LO Simenstad Nursing Care Unit
Luther Hospital - Mayo Health System
Luther Midelfort Northland - Mayo Health System
Luther Midelfort Chippewa Valley - Mayo Health System
Luther Midelfort Oakridge - Mayo Health System
Markesan Resident Home
Marquardt Memorial Manor
Mercy Manor Transition Center
Mercy Residential and Rehab Center
Montello Care Center
Morrow Memorial Home
Mt Carmel Medical and Rehab Center
Muskego Health Care Center
Nazareth Health and Rehab Center
Norseland Nursing Home
Oak Park Nursing and Rehab Center
Oak Ridge Care Center
Oakridge Gardens Nursing Center
Oconomowoc Memorial Hospital
Onalaska Care Center
Osceola Medical Center
Pine Crest Nursing Home
Pine Valley Healthcare and Rehab Center
Portage County Health Care Center
Prairie du Chien Memorial Hospital
Prescott Nursing and Rehab Community
Red Cedar Medical Center
Reedsburg Area Medical Center
Rennes Health Center - Appleton
Rest Haven Health Care Center
Ridgeview Terrace Long Term Care
Ripon Medical Center
River Falls Area Hospital
Riverview Hospital Association
Sacred Heart Hospital - Eau Claire
Santa Maria Nursing Home
Schmitt Woodland Hills
Select Specialty Hospital Madison
Shady Lane Inc
Shawano Medical Center
Southwest Health Center - Hospital
Southwest Health Center - Nursing Home
Spring Valley Health Care Center
St Clare Hospital and Health Services
St Clare Meadows Care Center
St Croix Regional Medical Center
St Joseph Hospital - Chippewa
St Marys Care Center
St Michaels Lutheran Home
Tomah Memorial Hospital
Upland Hills Health Hospital
Upland Hills Nursing and Rehab
Vallhaven Care Center
Villa Marina Health and Rehab - Superior
Waunakee Manor Health Care Center
Wheaton Franciscan Healthcare - St Joseph Elmbrook
Wild Rose Manor
Willowbrook Nursing and Rehab
Wisconsin Lutheran Care Center
Woodland Village Nursing Home
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GPRA Goal Update
The Centers for Medicare & Medicaid Services' (CMS) two Government
Performance Results Act (GPRA) goals for nursing homes include reducing the
number of restraints used and reducing the number of pressure ulcers in
nursing homes. These goals were first articulated in CMS Survey &
Certification (S&C) Letter number 05-01, titled Guidance on Working with
Quality Improvement Organizations. This S&C Letter can be viewed as a
PDF file at the Internet site http://www.cms.hhs.gov/SurveyCertificationGenInfo/
In July 2006, CMS Region 5 provided the DQA with regional GPRA goals for
pressure ulcers and restraints. The CMS Regional GPRA goal for pressure
ulcers was set at 7.4% and the goal for restraints was set at 4.5%. However,
Wisconsin's average percentage of restraints was already below the regional
Consequently, the DQA selected 2.6% as the Wisconsin GPRA goal for
restraints. Every quarter, the DQA monitors the progress of Wisconsin
nursing homes in achieving the GPRA goals. As of 6/13/08, Wisconsin's
average percentage of restraints remains at 1.7% based on fourth quarter MDS
data. Wisconsin's average percentage of pressure ulcers decreased to 6.8%
based on fourth quarter MDS data.
Prior to each nursing home's annual survey, state surveyors review each
nursing home's Quality Measure/Quality Indicator Reports to determine if the
nursing home's "observed percent" of pressure ulcers is 7.4% or
above and whether the "observed percent" of restraints is 2.6% or
above. The survey team must select these areas for review for any nursing
home whose "observed percent" is at or above these thresholds.
The DQA strongly recommends that all nursing homes routinely monitor
their Quality Measure/Quality Indicator Reports with their quality assurance
committee to determine if their "observed percent" is at or above
the thresholds for pressure ulcers and restraints. As the majority of
serious deficiencies issued in 2007 and 2008 for pressure ulcers were
related to lack of prevention, the quality assurance committee should also
review on a quarterly basis the number of pressure ulcers that are present
on admission versus facility acquired pressure ulcers.
If you have questions about GPRA goals, contact:
Vicky Griffin, WI GPRA Goal Coordinator
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Innovative Collaboration Paves the Way in Pressure Ulcer
State and Private Health Leaders Collaborate to Double Wisconsin
Pressure Ulcer Care Specialists
Ten organizations and the Department of Health and Family Services
announced a collaborative effort to certify 200 Wisconsin registered nurses,
who work in long-term care, as certified pressure ulcer specialists:
The courses, provided by the Wound Care Education Institute, will more
than double the number of pressure ulcer care certified nurses currently
working in Wisconsin. This increase aims to further prevent and better treat
the occurrence of pressure ulcers in nursing home residents.
This initiative marks Wisconsin as having one of the most aggressive and
comprehensive approaches to pressure ulcer prevention and treatment in the
nation. Wisconsin already is a national leader, well below the national
average and regional target numbers for pressure ulcer prominence. This
initiative to lower the occurrence of pressure ulcers in the state will
further solidify Wisconsin's role as an innovator in health care, committed
to the well-being of its residents.
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LTC Facilities to Protect Residents with Full Sprinkler
CMS to Publish Final Rule
Long term care (LTC) facilities across America will, for the first time,
be required to protect their residents by installing sprinkler systems
throughout their buildings if they wish to continue to serve Medicare and
Medicaid beneficiaries, under a new regulation to be issued by the Centers
for Medicare & Medicaid Services. Facilities will have a five-year
phase-in period to become fully compliant with the new rule.
Approximately three million elderly and disabled Americans reside in the
nation's 16,000 nursing homes, all of which must have comprehensive
sprinkler systems in place by 2013. To date, there has never been a
multiple-fatality fire in a facility with a sprinkler system that meets the
requirements of today's rule.
"CMS is taking further action to protect the lives of our
beneficiaries through a more comprehensive and effective approach to fire
safety," said Kerry Weems, acting administrator of CMS. "In the
past, certain older facilities were exempt from having an automatic
sprinkler system, but we now will hold all 16,000 nursing homes in the
nation to this standard."
As an interim step taken prior to publication of this rule, CMS in March
2005 began requiring all long term care facilities that did not have
sprinklers to install battery-operated smoke alarms in all patient rooms and
public areas. Although fatal fires in nursing homes are rare, in a July 2004
report, the Government Accountability Office estimated that automatic
sprinkler systems can decrease the chance of fire-related deaths by 82
CMS has already taken many actions to increase resident safety over the
past several years, including stepped-up frequency in the number of fire
safety inspections performed.
The agency previously began publishing on its Nursing Home Compare Web
site the number of fire safety violations, as well as information on the
extent to which nursing homes had sprinkler systems, for every long term
care facility in the country.
Under previous CMS regulations, newly constructed and rehabilitated
nursing homes must be equipped with sprinkler systems. But prior to adoption
of today's rule, existing homes were not required by the federal government
to have such systems.
CMS follows the fire safety guidelines developed by the National Fire
Protection Association (NFPA) and all new sprinkler systems installed as a
result of this rule will have to meet NFPA technical specifications. To be
in compliance with the new rule, nursing homes must have sprinkler coverage
in all areas such as resident rooms; kitchen, dining and activity areas;
corridors; attics; canopies; overhangs; offices; waiting areas; closets;
storage areas for trash and linen; maintenance areas, etc.
"This is an important new rule for protecting the health and safety
of persons living in long term care facilities such as nursing homes who
are, by definition, some of the most vulnerable among us," Weems said.
"It is widely believed by fire safety experts that automatic sprinkler
systems are the single most effective fire protection step facilities can
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New Nursing Home MDS Resource Guide
The DQA developed a Minimum Data Set (MDS) Resource Guide. This guide
provides websites and resource information related to the Resident
Assessment Instrument (RAI) and MDS. The MDS Resource Guide is available on
the following website and the printed document may be folded to form a
tri-fold. The MDS Resource Guide can be accessed at:
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Office of Caregiver Quality (OCQ) Updates
DQA Regulated Entity Background Check Process
If an entity wishes the license approval to continue, the license holder
or the legal representative must submit the completed forms that are
necessary for the required four-year renewal process, regardless of when
a DQA regulated entity last submitted an application for licensure,
certification, or registration.
Pursuant to Chapter 50.065(6)(am), Wis. Stats., and HFS 12.05, Wis.
Admin. Code, failure to comply with any provision of background information
gathering requirements subjects entities to certain sanctions, including
denial, revocation, non-renewal, or suspension of regulatory approval.
All license holders/legal representatives must comply with the
requirements by June 30, 2008. To obtain the necessary forms for the Existing
License Holder Four-Year Renewal Background Check Process, access the
DQA Regulated Entity Background Check Process web page at
See DQA Memo 08-015 for more information.
NNAAP Application for Competency Evaluation for Student Nurse or
Graduate Nurse Update
The OCQ and Pearson VUE have revised the student nurse application
process and developed the following procedure to ensure that a nursing
student or a graduate nurse has satisfactorily completed training in all six
care areas before applying to take the National Nurse Aide Assessment
Program (NNAAP) examination:
The Student Nurse or Graduate Nurse, who has not taken the National
Council Licensure Examination for Registered Nurses (NCLEX-RNŽ) or
Practical Nurses (NCLEX-PNŽ) must submit an original transcript and a
Student/Graduate Nurse Verification Sheet verifying that he/she has met all
training requirements for nurse aide program. The verification sheet must be
sent to the OCQ for approval.
- OCQ will review this information, indicate on the verification sheet
that the request to take the NNAAP is either approved or denied
(indicating reason for denial), and return the Student/Graduate Nurse
Verification Sheet to the applicant.
- If approval is granted, the applicant must submit the original
verification sheet authorization, a completed Application for
Competency Evaluation for Student Nurse or Graduate Nurse, the
correct fees, and appropriate forms of identification to the American
Red Cross for scheduling an exam.
A Graduate Nurse, who has failed the National Council Licensure
Examination for Registered Nurses (NCLEX-RNŽ) or Practical Nurses (NCLEX-PNŽ),
must complete an Application for Competency Evaluation for Student Nurse
or Graduate Nurse and submit a copy of the letter from the State Board
of Nursing verifying failure of the NCLEX, correct fees, and appropriate
forms of identification to the American Red Cross for scheduling an exam.
A Graduate Nurse, who holds a current nursing license (RN or LPN), must
complete an Application for Competency Evaluation for Student Nurse or
Graduate Nurse and submit a copy of his/her current nursing license,
correct fees, and appropriate forms of identification to the American Red
Cross for scheduling an exam.
The Application for Competency Evaluation for Student Nurse or
Graduate Nurse and the Student/Graduate Nurse Verification Sheet will be
available on the Pearson VUE website at http://www.pearsonvue.com.
Questions? Contact the DQA Office of Caregiver Quality at:
(608) 261-8319 telephone
(608) 264-6340 fax
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Sharing State Survey Findings with Managed Care
Organizations - Home Health
Effective with the conclusion of June 2008 surveys, DQA will share copies
of all state violations of HFS 12, HFS 13, and HFS 133 with the Department's
Office of Family Care Expansion. DQA will provide the Office of Family Care
Expansion with copies of all state-issued survey findings once it is
confirmed that the agency has received its original citation. That office
will, in turn, share these copies with the respective Managed Care
Organizations within the counties served by the home health agency.
Questions related to this sharing of information may be directed to:
Cremear Mims, Director, Bureau of Health Services.
(608) 264-9887 (Madison)
(414) 227-4556 (Milwaukee)
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Signature Stamps for Home Health Agencies and Hospices
The Centers for Medicare and Medicaid Services (CMS) S&C letter 08-22
provides updated survey and certification guidance related to the use of
physicians' signature stamps by Medicare-approved home health and hospice
providers. It updates S&C 04-35, published July 8, 2004.
CMS is no longer allowing home health agencies and hospices to accept
rubber stamp signatures from physicians. Stamped signatures cannot be
accepted on orders, treatments, or other documents that are a part of the
patient's clinical record.
Wisconsin home health agency and hospice administrative rules (HFS 133
and HFS 131 respectively) do not prohibit the use of a physician's rubber
stamped signature. The rules requiring a physician signature do not restrict
the form of that signature. However, licensed and certified agencies
must comply with the more restrictive Medicare rule. Therefore, this notice
rescinds the previous guidance provided in the November, 2004 Quarterly
If you have additional questions, please feel free to contact:
REMINDER: Basic Home Health Online Course
The Basic Home Health Online Course is an educational course that
provides individuals an opportunity to learn basic federal home health
regulations. This interactive course is intended to build a foundation of
understanding about home health agency federal regulations.
The federal home health agency Conditions of Participation (CoPs) and
Appendix B of the State Operations Manual (SOM) are the basis for this
course. Appendix B includes the regulations, interpretative guidelines, and
questions to consider when determining if home health agencies are following
Many home health agency staff have already taken the course and have
provided very positive feedback.
Register online at https://charge.wisc.edu/quality/training/courses.asp.
The cost to take the course is $25.00 per person. The course is available
24/7 via the Internet. Additional information is included in the course
description located on the registration website.
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Changes in DQA Staff
Bureau of Assisted Living Changes
New Bureau of Assisted Living Regional Director - SERO
The Bureau of Assisted Living (BAL) is pleased to announce that Carolyn
Happel (formerly Lien) has accepted the position of Assisted Living Regional
Director of the Southeast Regional Office.
For the last six years Carolyn has worked for DHFS as a Human Services
Area Coordinator (Area Administration) for adult services. In that role, she
collaborated extensively with the SERO to help improve Assisted Living
programs. Prior to that time Carolyn spent four years with Washington County
Department of Social Services and worked as a Director of Social Services
for a nursing home.
Jennifer Wagner Departure
Jennifer Wagner served as a Quality Assurance Program Specialist for the
Bureau of Assisted Living. Jennifer had a tremendous impact on the bureau's
ability to improve quality assurance mechanisms, to target resources on high
impact areas, and to look at corporate compliance concerns. Jennifer's last
day with DQA/BAL was June 6th.
Marilyn Wendelburg Departure
After almost 28 years with the Division of Quality Assurance, Marilyn
Wendelburg is retiring on July 10th. Marilyn began her career as a nurse
consultant surveyor in the Bureau of Nursing Home Resident Care in the
southeast region and, then, with the Bureau of Assisted Living.
Announcing a Change in the NRO and NERO
Barbara Brock-Arndt, Northern Region Assisted Living Regional Director,
has accepted a Nursing Consultant 1 position in the BAL Northeast Regional
Office. DQA thanks Barbara for her years of service and contributions to the
BAL. Barbara will begin her new position July 6, 2008. Susan Murphy, Western
Regional ALRD, will provide ALRD coverage to the Northern Region.
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DQA Numbered Memos (April, May, June)
Access these memos via http://www.dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm
or from individual providers' publications pages via http://www.dhs.wisconsin.gov/rl_DSL/
Informal Dispute Resolution
This memo describes the revised procedure under which
health care facilities may work to informally resolve differences they
have with citations issued by the DQA. The procedure took effect
Monday, April 14, 2008.
Nursing Homes, Facilities for the Developmentally Disabled
Post-Construction Inspection Questionnaire for
The Bureau of Health Services (BHS) has implemented a
satisfaction survey for hospitals receiving construction inspections
by the BHS engineering staff. This survey tool provides hospital
representatives or their contractors an opportunity to provide
feedback to management staff of the BHS about the inspection process.
Revisions to Wisconsin Statutes, Chapter 50,
Effective March 29, 2008
Wisconsin Act 102 went into law on 03/13/08 and
created section 50.375, effective 03/28/08. Section 50.375 requires
hospitals to provide a victim of sexual assault with specific
information and, upon the victim's request, emergency contraception.
The DHFS is responsible for ensuring that hospitals
comply with the requirements of section 50.375 and is authorized to
directly assess forfeitures for violations of the law.
Submission of Construction Plans to the Milwaukee
State Office Building
This memo informs certain design firms and health
care facilities that they will need to direct construction plans for
DQA review to a new address. The change, which takes effect
immediately, affects healthcare facilities located in the Eastern
part of Wisconsin.
Ambulatory Surgery Ctrs., Community Based Residential Facilities,
End Stage Renal Dialysis Units, Hospices, Hospitals, Nursing Homes
Medication Aide Training Waiver for Facilities with a
Nurse Aide Training Prohibition
This memo details the circumstances under which
medication aide training can be allowed in facilities with an NATCEP
prohibition (an enforcement action taken when a facility has citations
for substandard quality of care).
Glucose Meters and Infection Control
The DQA has observed instances where facility staff
have not adhered to the standards of practice to prevent
patient-to-patient transmission of blood borne pathogens when using
The memo provides specific infection control
recommendations published by the CDC that focus on diabetes-care
procedures in healthcare and group residence settings.
Adult Family Homes, Community Based Residential Facilities,
Facilities for the Developmentally Disabled, Nursing Homes, Residential Care Apt.
Wisconsin Nurse Aide Training Clinical Site
This memo provides nursing homes with information
regarding their role and responsibilities when agreeing to serve as a
clinical site for an approved nurse aide training program.
Nurse Aide Training Programs, Nursing Homes
Notice of Mandatory Requirement to Submit Four-Year
Renewal of Licensee background Check Information
This memo serves as official notice to entity license
holders/legal representatives that the DQA is now conducting the
required four-year renewal of licensee background checks.
Certified Mental Health and AODA, Community Based Residential Facilities,
Facilities for the Developmentally Disabled, Home Health Agencies, Hospices,
Hospitals, Licensed Adult Family Homes, Nursing Homes, Residential Care Apt. Complexes
DQA Complaint Resources
The memo introduces the new DQA online and toll-free
Ambulatory Surgical Ctrs., Adult Day Care Facilities,
Adult Family Homes, Community Based Residential Facilities, End Stage Renal Dialysis Units,
Facilities for the Developmentally Disabled, Home Health Agencies, Hospitals,
Hospices, Nurse Aide Training Programs, Nursing Homes, Outpatient Rehabilitation Agencies,
Residential Care Apt. Complexes, Rural Health Clinics, Disability Rights of Wis.,
Board on Aging and Long Term Care, Coalition of Wisconsin Aging Groups
08-017 - Change in Regional Boundaries and Regional Contacts - OBSOLETE 9/13
The current country responsibilities for certain
regional offices have changed effective 06/01/08.
Reporting Hotline for Health Care Providers
The purpose of this memorandum is to notify health
care providers of the method for contacting the Department of Health
Services (DHS) to report public health or human service emergencies.
Adult Day Care Centers, Adult Family Homes,
Ambulatory Surgery Ctrs., Certified Mental Health and AODA, Community
Based Residential Facilities, Home Health Agencies, Hospices,
Hospitals, Nurse Aide Trng. Programs, Nursing Homes, Outpatient
Rehabilitation Facilities, Residential Care Apartment Complexes, Rural
Statewide Waiver of Certain Sections of Wis. Admin.
Code Chapter HFS 88, Relating to the Provision of Information to an
Aging and Disability Resource Center and Referral to a Resource
With the passage of the State's budget (2007 Wis. Act
20. §§ 1765, 1766, and 1767), Adult Family Homes (AFHs) in counties
with a resource center certified by the Secretary of the DHFS are no
longer obligated to meet the requirements in Wis. Admin. Code §HFS
10.73(3) and (4).
The purpose of this statewide waiver is to notify
facilities of the elimination of the statutory requirement to (a)
provide information about the services of an aging and disability
resource center and available screening for family care benefit
eligibility, and (b) the requirement to make referrals to an aging and
disability resource center.
Adult Family Homes
08-020 - Recent FDA Medication Recalls and Compliance - OBSOLETE 9/13
The Centers for Medicare and Medicaid Services (CMS)
has become aware, during facility surveys nationally, of instances
where facilities have not been in compliance with various Food and
Drug Administration (FDA) recalls.
Recent recalls have included heparin products and
Digitex Ž. These recalls were due to adverse effects occurring in
patients, including deaths. Therefore, facility removal of the
recalled products is imperative for patient safety. The FDA
information on recalled products and lot numbers may be accessed at
the FDA Web site located at http://www.fda.gov/opacom/7alerts.HTML
Pharmacy providers and distributors and health care providers should
be monitoring their supplies, including, for example, crash carts and
storage cabinets, and removing recalled products in order to assure
that recalled products are not available for patient/resident use.
Adult Day Care, Adult Family Homes, Ambulatory
Surgery Ctrs., Certified Mental Health and AODA, Community Based
Residential Facilities, End Stage Renewal Dialysis, Facilities for the
Developmentally Disabled, Home Health Agencies, Hospices, Hospitals,
Nurse Aide Training Programs, Nursing Homes, Outpatient Rehabilitation
Agencies, Residential Care Apartment Complexes, Rural Health Clinics
Wisconsin Feeding Assistant Training Program Update
The DHFS has recently received a number of questions
as to whether licensed health care professionals are required to
complete a feeding assistant training program prior to assisting
residents, who have no feeding complications, with the activities of
eating and drinking. This memo provides clarification as to what
extent the training requirement in 42
CRF 483.75(q) applies to licensed health professionals as defined
in 42 CFR 483.75(e)(1).
Facilities for the Developmentally Disabled, Feeding
Assistant Training Programs, Nursing Homes
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HFS Administrative Rules Update
HFS 12 - Caregiver Background Checks
On May 15, 2008, the Wisconsin Administrative Register published a
Statement of Scope of proposed rules to revise Chapter HFS 12, Caregiver
Background Checks. 2007 Wisconsin Act 172 created section 50.065 (2m) (d) of
the Statutes, effective April 10, 2008. Section 50.065 (2m) (d) requires the
Department to promulgate rules to specify crimes for which an entity must
disclose to a client or the client's guardian, a conviction of a caregiver
who is assigned to provide personal care services to the client in the
client's personal residence and to specify who is a "substitute
An advisory committee has been formed, including advocates, trade and
professional associations, and other interested parties, to review the
proposed revisions and make recommendations for change. For more
information, you may view the Statement of Scope on the Wisconsin
Administrative Rules website at https://health.wisconsin.gov/admrules/public/Home.
HFS 83 - Community Based Residential Facilities
On October 18, 2007 the Wisconsin Administrative Register published the
Initial Proposed Rulemaking Order including a summary and text of the
proposed rule, Wisconsin Administrative Code Chapter HFS 83. The goal of the
proposed rule is to focus on resident outcomes and quality of life and
quality of care, improve readability and organization, eliminate excess and
prescriptive language, revise staff training standards establishing a more
cost effective system for providers, and promote the use of nationally
recognized standards of practice.
Public hearings were held in December 2007 in five locations; Eau Claire,
Milwaukee, Green Bay, Rhinelander, and Madison. For more information, you
may view the proposed rule on the Wisconsin Administrative Rules website at https://health.wisconsin.gov/admrules/public/Home.
HFS 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 HFS 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, meets regularly to
review proposed rule language and make recommendations for revision to the
rule. For more information, you may view the Statement of Scope on the
Wisconsin Administrative Rules website at https://health.wisconsin.gov/admrules/public/Home.
HFS 124 - Hospitals
On April 1, 2005, the Wisconsin Administrative Register published a
Statement of Scope of proposed rules to amend Chapter 124. The Department is
planning to update Chapter HFS 124 to eliminate overly prescriptive and
outdated regulations, clarify the Department's enforcement authority, and
make the rule more consistent with the federal Medicare requirements.
An advisory committee has been formed, including a large number of trade
and professional associations, hospitals, and other interested parties, to
review the proposed revisions and make recommendations for change. For more
information, you may view the Statement of Scope on the Wisconsin
Administrative Rules website at https://health.wisconsin.gov/admrules/public/Home.
HFS 129 - Certification Programs for Training and Testing Nurse
Assistants, Home Health Aides and Hospice Aides
On May 6, 2008, the Wisconsin Administrative Register published the
Initial Proposed Rulemaking Order including a summary and text of the
proposed rule, Wisconsin Administrative Code Chapter HFS 129. Through this
initiative, the Department proposes to make the rule more consistent with
federal regulations, to include the feeding assistant and medication aide
training and testing program requirements, and to reflect the Department's
decision to standardize administration and operation of nurse aide
competency evaluation by contracting for this service.
Public hearings were held in June 2008 in 4 locations; Milwaukee, Wausau,
Rice Lake and Madison. For more information, you may view the proposed rule
on the Wisconsin Administrative Rules website at https://health.wisconsin.gov/admrules/public/Home.
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CMS Survey & Certification Letters (April, May, June)
Listed below are Survey and Certification (S&C) Letters distributed
by CMS during the last quarter. Please note that the CMS Internet site where
you can review all S&C memos is
Federal Minimum Qualification Standards for LTC
Registered QIS Surveyors
Includes Federal minimum standards of the QIS process
to assure effective and consistent QIS implementation for the training
of State and Federal surveyors and their trainers.
Revised State Operations Manual Appendix V - EMTALA
Advanced copy of the Emergency Medical Treatment and
Labor Act (EMTALA) Appendix V to Publication 100-07, State Operations
Manual (SOM), incorporates recent guidance provided in S&C
memoranda, technical corrections, and revised Tag numbers.
Provisions of Observation Services in Critical Access
Includes advanced copy of revised portions of the
State Operations Manual (SOM) CAH Appendix W, addressing assessment of
observation bed services in CAHs.
Critical Access Hospitals
Transplant Surveys: Guidance for Citing Condition and
Provides guidelines for determination of level of
non-compliance when deficiencies are cited under clinical experience
requirements or survival outcome requirements in organ transplant
Hospitals, Organ Transplant Programs
Restraint/Seclusion Interpretive Guidelines and
Updated SOM Appendix A
On-line SOM Hospital Appendix A requires revision
reflecting changes in regulatory text adopted through rulemaking by
CMS, established interpretive guidance issued via previous S&C
memoranda, new interpretive guidance for patients' rights rule at 42
CFR 482.13(e), (f) and (g), governing hospital use of restraint and
seclusion, minor technical corrections, and revision of Tag numbers.
Alert: Food and Drug Administration (FDA) Heparin
Recall for All Provider Types
The FDA has issued recalls for medications that have
the potential for serious adverse reactions in patients/residents. It
is important that all health care providers are aware of this
All Provider Types
Safe Injection Practices in Ambulatory Surgical
The State of Nevada and federal epidemiologists
identified a cluster of hepatitis C infections where infected
individuals all had procedures in the same ASC. Subsequent survey of
that ASC identified unsafe injection practices. The CDC has developed
pertinent information on safe injection practices. State Agencies
should disseminate this information to certified ASCs in their States
and ensure that all surveyors who conduct ASC surveys are familiar
with this material.
Ambulatory Surgical Ctrs.
Updated Brochure Describing the Quality Indicator
CMS is providing an updated, 2008 version of the
brochure that provides a brief description of the QIS and an overview
of the QIS training process.
Signature Stamps for Home Health Agencies (HHAs) and
Effective 05/30/08 HHAs and hospices may not accept
physicians' rubber stamp signatures for their clinical record
documenta-tion. This memo updates S&C-04-35, published 07/08/04.
Home Health Agencies,Hospices
SOM Chapter 5 / Release of Person-Identifiable Data
Related to Restraint / Seclusion Deaths to PA and As
Sec. 5140 of Pub. 100-07, the SOM, concerning deaths
in Hospitals associated with the use of restraint or seclusion, has
been revised to correspond to regulatory requirements at 42 CFR
482.13(g) and to reflect operational procedures implemented since the
revised regulation took effect in January, 2007. An advance copy of
the revised SOM Sec. 5140 is attached.
DMEPOS Competitive Bidding Replaces Current Fee
Schedule Amounts for Selected Items in Some Areas
This memo provides information concerning a recent
change in the way payment is made for durable medical equipment to
DMEPOS suppliers. Surveyors, especially those surveying home health
agencies, hospices, and nursing homes should be aware of this change
in payment in the event questions arise during the course of a survey.
Home Health Agencies, Hospices, Nursing Homes
Advance Copy - Organ Transplant Interpretive
The Organ Transplant Interpretive Guidelines
represent the most recent surveyor guidance for conducting surveys of
organ transplant programs and should replace all previously-released
Hospitals, Organ Transplant Programs
Moratorium on Classification of Long-Term Care
The Medicare, Medicaid, and SCHIP Extension Act (MMSEA)
(Pub. L. 110-173), enacted December 29, 2007, establishes a three-year
moratorium on the designation of new long-term care hospitals (LTCH)
or satellites, and on an increase of beds in an LTCH. The statute
creates certain limited exceptions to the moratorium. The Centers for
Medicare and Medicaid Services adopted an Interim Final Rule with
Comments on May 22, 2008 (73 FR 29699) to implement the LTCH
moratorium provisions of the MMSEA. CMS Regional Offices will
determine whether a facility qualifies for an exception to the
Hospitals, Long Term Care Hospitals
Survey and Certification Issues Related to Iowa and
Indiana Flooding Disasters
The President has declared a national emergency in
specified counties of Indiana and Iowa, and Mike Leavitt, the
Secretary of the U.S. Department of Health and Human Services, has
also declared a public health emergency in the specified Indiana and
Iowa counties. CMS may waive or modify, to the extent necessary,
certain requirements or timetables, if providers, acting in good faith
to provide needed services, are unable to comply with the requirements
as a result of the effects of the disaster.
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Focus 2008 Conference - Navigating the Waters of Emerging Issues
The Wisconsin Department of Health Services, Division of Quality
Assurance is pleased to announce the 8th Annual Conference for health care
providers and DQA staff on August 6, 2008. This year's conference, developed
in collaboration with health care providers, is designed to bring together a
variety of experts to share strategies and provide learning opportunities
for all participants.
Karen E. Timberlake, Secretary of Health Services, will kick off the
conference with opening remarks. Cheryl Kirking --- author, Certified
Personality Trainer, songwriter, and recording artist --- will present a
motivating, thought-provoking keynote, "Splashes of Joy".
The day will include 24 topical breakout sessions on emerging issues and
practices, numerous informative exhibits, and networking opportunities.
The FOCUS 2008 conference offers an exciting opportunity for participants
- acquire information from experts to address current and emerging
- apply learned practices and strategies in their health care settings
- gain opportunities for networking and the exchange of ideas.
The conference is designed for staff from Assisted Living Facilities,
Facilities Serving People with Developmental Disabilities, Nursing Homes,
and DQA. Online registration and additional information on the presenters,
breakout sessions, and exhibits is available at
The conference will include a special session, "Spotlight on Complex
Issues in Bariatric Health Care," on August 5 which will focus on the
unique issues and concerns related to the treatment of persons who are more
than 100 pounds overweight. The conference begins with a keynote address by
Dr. Lloyd Stegemann, President of the Texas Association of Bariatric
Surgeons and Advisory Board Member of the Obesity Action Coalition. This
engaging presentation will address the development and causes of the current
obesity epidemic, as well as the economic, health, and social impact of
society's expanding waistlines.
The afternoon breakout sessions will feature specialists in the field of
bariatrics. The sessions are designed to provide increased understanding of
morbid obesity and to offer practical approaches that can be applied in
health care facilities, home health, and community environments. Topic areas
include equipment demonstrations, consumer advocacy, skin care, mobility
challenges, caregiver safety, selection of equipment, psychological factors,
and provider panel discussions.
This special session is designed for staff from all provider types, as
well as Occupational Therapists, Physical Therapists, Emergency Medical
Services Personnel, and staff from DQA.
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Content contact: Gina
Phone: (608) 266-6691
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