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DQA Quarterly Information Update

July 2009

PDF Version of this month's Quarterly Update (PDF, 163 KB)




  • FOCUS 2009 Conference - October 21 - 22


FOCUS 2009 Conference
Bureau of Technology, Licensing and Education / Education Services Section

Wednesday, October 21 - Special Sessions
Thursday, October 22 - FOCUS 2009

The Wisconsin Department of Health Services, Division of Quality Assurance (DQA), is pleased to announce its 9th annual conference for health care providers and DQA staff on October 21st and 22nd, 2009. The FOCUS 2009 Conference, being developed in collaboration with health care providers and associations, is themed "Furthering Our Commitment to Ultimate Service". This year's conference has an all-star lineup of presenters to help improve your day-to-day work and bring the best service possible to the consumer.

A FOCUS 2009 "Save the Date" postcard was mailed out this spring. In early August the brochure will be mailed and posted on the DQA website. At that time registration for the conference will begin.

This year the conference will be held at:

Kalahari Convention Center
1305 Kalahari Drive
Wisconsin Dells, WI

For lodging information, contact the Kalahari Convention Center at 1-877-525-2427. Be sure to mention the FOCUS 2009 Conference for the special room rate.

On October 21st, two special sessions will be offered. Attendees will have the option of attending "The Art and Science of Pressure Ulcer Prevention and Treatment" or "ServSafe® Essentials." "The Art and Science of Pressure Ulcer Prevention and Treatment" will feature pressure ulcer expert Joyce Black, Ph.D., former president of the National Pressure Ulcer Advisory Panel. 

This conference will have break out sessions featuring many experts in the field. The ServSafe® course will be taught by Certified ServSafe® Instructor, Rich Daehn. He will explain food safety and the critical importance of its role. Upon successful completion of the ServSafe® Essentials course, participants will be given the opportunity to take an approved exam to become ServSafe® Certified.

On October 22nd, the FOCUS 2009 Conference will feature two keynote speakers. Dr. Gregory Poland will kick off the conference with a presentation entitled, "Influenza Immunization of Health Care Workers." Dr. Poland is an international expert in the field of vaccinology and clinical research and is the director of Mayo Clinic's Vaccine Research Group.

In the afternoon, the keynote speaker will be Clint Maun. The title of Clint's presentation is, "Yes We Can!" Clint is a nationally recognized leader in healthcare consulting, speaking, and research.

The agenda for this conference is loaded with great presenters and current topics that are of importance to consumers. More information will be included on DQA's conference website as plans are finalized. For additional information, please visit the website at:

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Recall: Biosite Brand Triage Cardiac Panel
Bureau of Health Services / Clinical Laboratory Section

DQA is alerting emergency care managers, hospital risk managers, and laboratory services managers of the Class 1 recall of the Biosite brand Triage Cardiac Panel, a test used by health professionals as an aid in the diagnosis of a heart attack (myocardial infarction).

Use of the affected lot may lead to false negative results with patient samples containing troponin I at very low levels, with CK-MB, and with myoglobin --- possibly resulting in missed or incorrect diagnosis. A false negative test result would indicate that a person did not have a heart attack or heart muscle injury when, in fact, they had.

Lot #W44467B, shipped as 25 individually pouched devices per kit box, was distributed from January 24, 2009 through February 17, 2009. On April 27, 2009, the company issued an urgent recall notice to customers who were instructed to immediately discontinue all use of and to discard all affected products.

Read the complete MedWatch 2009 Safety summary, including a link to the FDA recall notice, at:

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Non-LTC Providers - Recent Survey Trends
Bureau of Health Services / Acute Care Compliance Section

The Bureau of Health Services has seen an increase in the number of serious level deficiencies identified during surveys of non-long term care providers. Acknowledged is the fact that most non-long term providers are operating under new Medicare Conditions of Participation or Conditions for Coverage.

Recent communications from the Centers for Medicare and Medicaid Services (CMS) may assist you in evaluating whether you have thoroughly investigated and implemented corrective actions to ensure ongoing compliance with regulatory requirements. These are guidelines CMS shares with surveyors who may be asked to determine a provider's compliance.

Surveyors use a variety of tools during a survey which may include review of provider records and documentation, staff and patient/client interviews, observations, and tours. Following are some of the inquiries that might be made:

Tell me what you did in response to this problem.

What analysis of the underlying cause(s) was done?

When did you address it?

Were policies written or revised? If so, what were they?

Was training conducted?

What corrective action(s) was implemented?

What follow-up monitoring of these actions is being done and who is doing the monitoring?

Has the problem been entered into the facility's quality assurance performance improvement program?

Or, have you discussed the problem with your Governing Body? If not, why?

Please show me documentation of committee minutes where the problem was discussed or minutes of your governing body committee meetings where the problem was discussed.

Citations for non compliance may be issued if the problem is still occurring. If mechanisms put into place to address the original problem are not monitored and tracked to ensure sustainability, the problem may likely recur.

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Coming Soon! DHS 83 Q & A
Bureau of Assisted Living

Bureau of Assisted Living (BAL) staff are compiling a question and answer document regarding the implementation of Wisconsin Administrative Code DHS 83 for Community-Based Residential Facilities. Since the new requirements went into affect April 1, 2009, BAL staff have received a number of questions regarding the department's interpretation of the regulation. We hope the Q & A document will help clarify the regulation and assure consistent application of the requirements. 

The Q & A document is expected to be posted to the department's web site sometime in July. When posted, an announcement will be sent via the DQA LISTSERV with the web site link.

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New Outpatient Mental Health Clinic Rule
Bureau of Health Services / Behavioral Health Certification Section

On June 1, 2009 a new administrative code, DHS 35, for Outpatient Mental Health Clinics took effect. This rule replaced HFS 61.91 with modern standards for psychotherapeutic care, oversight, and consultation. Outpatient mental heath has advanced as new treatment modalities and knowledge were gained, technologies improved, specialties defined, and business models adapted.

The rule was authored by the Division of Mental Health and Substance Abuse Services (DMHSAS) and incorporates improvements, public comment, and addresses variances issued in past years. DHS 35 affects approximately 840 service providers. The new rule is available on-line at:

The DMHSAS and DQA are committed to assisting clinics in achieving full compliance with program standards within one-year's time. Because there have been so many changes to DHS 35, clinics have until January 1, 2012 to meet the new standards for minimum staffing combinations. Questions regarding legislative intent and interpretation may be directed to:

Dan Zimmerman
DMHSAS / Bureau of Prevention, Treatment and Recovery
(608) 266-7072

The DQA Behavioral Health Certification Section (BHCS) monitors all mental health providers, including outpatient clinics. Support may be received through the provider's regional Health Service Specialists with application questions directed to: 

BHCS Central Office
(608) 261-0657

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Telehealth for Behavioral Health Service Providers
Bureau of Health Services / Behavioral Health Certification Section

Since 2004, the Division of Quality Assurance has accepted "telehealth" applications to certify behavioral health services delivered via streaming media. Telehealth was first addressed via numbered memo series, DDES-2004-014, now located at:

Telemedicine is conducted in many spheres of primary medicine. The effectiveness of telemedicine is evidenced in research and, once tried, is generally approved of by patients and providers alike. For the program director, telehealth services are found to be an effective means of extending the access to services which otherwise may be delayed or not be available at all. The business manager, insurance payer, and patient will also find that telehealth is efficient, providing a savings in the total cost of service delivery.

Many behavioral health services are eligible to be delivered via telehealth. While most certified telehealth services have been in mental health and substance abuse outpatient treatment programs, some program directors have discerned the usefulness of this modality within day treatment, crisis and emergency care, community support programs, and even a prevention service. Applications may be made to the Behavioral Health Certification Section and are available on-line at:

Questions regarding telehealth may be directed to (608) 261-0657.

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Effective August 1, 2009:
Iron, Price, and Sawyer Counties to Have Managed Care

Administrator's Office

On June 19, 2009, the Division of Quality Assurance issued DQA memos 09-023 (CBRFs), 09-024 (RCACs), and 09-025 (Nursing Homes) outlining the Preadmission Consultation (PAC) requirements for providers, effective July 1, 2009. The memoranda are available at:

The memoranda identify certain information dissemination and referral responsibilities that affect facilities in counties with Managed Care/IRIS (self-directed supports waiver) and in counties where Medicaid Waiver programs are available. Currently, managed care is not available in all counties. When managed care is made available in a county, new PAC requirements take effect. DQA will continue to publish the Managed Care Organization (MCO) start dates in the DQA Quarterly Information Update to inform providers when the new PAC requirements go into effect.

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Quality of Life and Environment Changes
Bureau of Nursing Home Resident Care

CMS introduced new guidance on specific Quality of Life and Environment tags which became effective on June 17, 2009. Although the regulations have not changed, the interpretative guidance to surveyors has expanded to include culture change and person-directed care concepts.

The word "homelike" stresses the concept of a setting as close to home as possible. A homelike environment can be achieved in a nursing home once residents have a sense of feeling at home. As we move away from an institutional feeling toward a more natural sense of home, the new guidelines provide a balance between person-directed care and regulatory requirements. Although not all of the guidance is new, Federal tags that have been expanded include the following:

F172 - Access and Visitation Rights. Access to visitors at times convenient for those living in the nursing home is part of creating an environment like that of one's home. The facility's right to reasonable restrictions does not include limiting visiting hours.

F241 - Dignity. Staff should both encourage and assist residents to dress in their own night clothing rather than hospital type gowns. Encouragement plays a role in this new guidance since some persons living in an institutional setting may have become accustomed to this type of facility practice.

When staff are assisting residents or providing cares, the guidance mentions that staff should be interacting and conversing with the residents rather than only with each other. It is a violation of dignity for staff to ignore residents and to talk only to each other as if the resident is not present.

Language has also been added to this tag that staff should avoid use of undignified labeling of residents. This includes descriptive words such as "wanderer," "eloper," or "feeder." The movement is toward the use of first person language and away from institutional language. A wheelchair-bound resident is more appropriately referred to as "a person who uses a wheelchair."

Another homelike concept that has been added as an option (not a requirement) relates to bodily privacy in the bath and shower. One method of ensuring privacy is to take persons to bathing areas in their clothing and to change them there rather than escorting them in a hospital gown with an opening in the back.

F242 - Self-Determination and Participation. The guidance at this tag enhances choices regarding bathing, including the timing and day of the week as well as a choice of bathing method. In 2002 CMS introduced the "bathing without a battle" method of in-bed cleansing, which is now considered an option for those living in the nursing home.

Language has also been added to the guidance regarding the right to choose a room with a person of the resident's choice. This is not limited to a husband and wife, but includes anyone residing in the nursing home (as long as both residents agree), including family members or two friends of the same or opposite gender.

F246 - Accomodation of Needs. The new guidance at this tag focuses on the physical environment and goes beyond the resident's bedroom and bathroom. The language stresses the concept of the facility attempting to add some individualization to the environment in common areas. This is not a regulatory requirement, but it is a homelike option that is encouraged.

When discussing accommodation of needs the concept of reasonableness is to be determined on a case-by-case basis.

F247 - Room/Roommate Change. Guidance has been added to provide specificity and to encourage the nursing home to be sensitive to resident needs when moving to a new room or when getting a new roommate. In the case of the death of a resident, the roommate may be experiencing a loss. It is encouraged that the resident be given some time to begin their adjustment and to grieve prior to introducing a new roommate.

F252 - Environment. The main focus of this tag consists of two issues:

1. general comfortableness of the environment; and

2. homelike environment.

Examples of institutional practices that a facility should strive to eliminate include:

  • overhead paging
  • meals served on trays in the dining room
  • institutional signage that label rooms
  • medication carts
  • widespread use of audible seat and bed alarms
  • mass purchased furniture
  • nurse's stations

Guidance indicates that most homes cannot make these changes right away but should strive toward them. It is not considered a deficiency if these practices remain.

F256 - Lighting. Guidance for adequate lighting addresses several issues for both the resident and facility staff. Adequate lighting design must:

  • be sufficient
  • produce minimal glare
  • provide even lighting in common areas
  • provide as much daylight as possible
  • eliminate glare from shiny floors and unshielded windows

Daylight is excellent for resident health and should be encouraged when possible.

In addition to lighting, guidance has been added to cue homes about the use of contrasting coloring to enhance a resident's ability to distinguish surfaces from each other. Areas of concern are baseboards that are the same color as the floor, bathroom fixtures that are the same color as the walls, and dinnerware that is the same color as the tablecloths.

F371 - Sanitary Conditions. The new guidance at this tag makes it clear that any resident has the right to accept food that is brought in by any visitors.

F461 - Resident Rooms. This tag was updated to include the LSC 2000 edition which replaced the outdated reference. Wording from the LSC was added to clarify that the height of the window sills in resident rooms must not exceed 36 inches. Language also clarified that the floor of the bedroom must be at or above the surrounding exterior ground level.

F461 and F255 - Two tags both addressed closet spaces. The two requirements were moved together and F255 has been deleted. The guidance makes it clear that the clothes racks and shelves (if any) need to be accessible to the resident, meaning that the resident can get to and reach their clothing. Closets also include free standing furniture such as a wardrobe. If a facility uses a wardrobe, the racks and shelves need to be accessible to the residents.

F463 - Call System. Language has been added to address homes that do not have nursing stations and homes that use wireless systems. The guidance for this tag adds language that, to be in compliance, the system must not only be merely functional but that it must actually be in use. That is, that calls must be answered. The system is in compliance if it is effectively functional, functioning, and if staff are actually responding to calls.

A complete presentation on the new guidance for Quality of Life and Environment Federal tags can be found at:

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Requirements for Laboratory Director - CLIA Certified Laboratory
Bureau of Health Services / Clinical Laboratory Section

The Clinical Laboratory Section frequently receives calls regarding the requirements for a Laboratory Director of a CLIA certified laboratory. The requirements depend both on the type of CLIA certificate required and the complexity of testing performed. The types of certificates and complexity of testing are:

  1. Certificate of Waiver - allows only waived laboratory testing to be performed
  2. Certificate of Provider Performed Microscopy (PPM) - allows providers to read simple microscopic procedures and perform waived testing
  3. Certificate of Compliance/Accreditation for a Moderately Complex Laboratory
  4. Certificate of Compliance/Accreditation for a Highly Complex Laboratory

These requirements can be found on the web at:

For additional information, please contact the Clinical Laboratory Section at (608) 261-0653.

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Bureau of Health Services / Clinical Laboratory Section

The Clinical Laboratory Section may be contacted regarding CLIA certification --- application for CLIA certification, questions pertaining to current certificate status, renewal, and requests for certificate changes.

DHS / Division of Quality Assurance
BHS / Clinical Laboratory Section
P.O. Box 2969
Madison, WI 53701-2969
Telephone: (608) 261-0653
FAX: (608) 264-9847

Requests for changes in certificate information are now required to be made in writing. Requests may be submitted by mail, FAX, or e-mail to:

Barbara Saar, QAPS
Telephone: (608) 261-0653
FAX: (608) 264-9847


Cherie Williams
Telephone: (608) 261-0654
FAX: (608) 264-9847

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Bureau of Technology, Licensing and Education / Technology Services Section

Current Status

CMS submitted the current draft of OASIS-C, version 12.2, on March 9 for approval from the Office of Management and Budget (OMB). OMB's intent in reviewing the data collection instrument is to focus on the burden posed to Home Health Agencies, as compared with the current OASIS-B1. A second public comment period ended April 8 and resulting comments were submitted only to the OMB for use in their analysis. 

As of June 16, a CMS spokesperson reported that OMB had neither granted clearance nor submitted comments/questions back to them. Once this occurs, there may need to be an additional revision of the dataset, though CMS and the Home Health industry is expecting this to be minimal. The dataset will also go through a Notice of Proposed Rulemaking (NPRM) process.

To obtain a copy of the current OASIS-C version 12.2, go to the Home Health Quality Improvement website at

Next Steps

CMS remains on task for the anticipated final version of OASIS-C to become effective January 1, 2010, unless unforeseen circumstances intervene. CMS is planning Open Door Forums, National Provider Calls, Listserv notices, and software "Vendor Calls" this summer after publication of the final version of the dataset. 

CMS has also announced plans to develop a free, 4-hour Medicare Learning Network training program to be used by Home Health Agencies, as well as a re-write of related portions of the OASIS Implementation Manual, including the Item-by-Item Tips in Chapter 8.

State OASIS Education Coordinators (OECs) will tentatively receive CMS-sponsored training on OASIS-C mid-September and will then conduct subsequent state-sponsored training sessions within their respective states. Wisconsin is planning to hold multiple OASIS-C training sessions for HHAs around early November, if the anticipated timeline remains unaltered. These training dates/locations will be posted to the DQA training page when finalized at:

The new OASIS-C data items include new structure, process, and outcome elements that are capable of capturing new process reports, outcome-based quality monitoring (OBQM), and outcome-based quality improvement (OBQI) reports, as well as for publication on Home Care Compare. OASIS-C includes clinically relevant measures that can be used to reflect the agency's use of evidence-based best practices, such as influenza vaccination rates. 

The National Quality Forum (NQF) has been working to "globally harmonize" reporting measures across all post-acute health care settings and has endorsed 20 new homecare quality measures toward this effort, with 4 more pending. CMS anticipates public reporting on the new measures to begin in Spring 2011.

To view the NQF press release and the 20 endorsed quality measures, go to the NQF website at:


There are several things an agency can do now to prepare for OASIS-C, prior to the publication of the final dataset. Some suggestions are:

  1. First, obtain a copy of version 12.2, as outlined above. Examine each of the data questions. Some of the questions are best answered using standardized industry-accepted assessment tools, e.g., pain assessment. If your agency doesn't have these, you will want to do some research and obtain them, then put them into practice.

  2. Many of the questions require "look back" information, such as care given or symptoms experienced during the previous certification period. This information will be difficult to retrieve if the clinician who needs to collect OASIS is not the primary clinician who has been caring for the patient, unless your agency has a standardized location to document and retrieve this information. This could significantly affect the amount of time it takes to complete an OASIS/comprehensive assessment. Identify which questions require this "look back" and start discussions with your clinicians to recommend where to document these items for quick/easy retrieval.

  3. Whether your agency uses software or paper documentation, contact your vendor now to obtain drafts of their proposed documentation, so you can be somewhat prepared for what your agency will be using. Be sure to obtain each assessment (e.g., SOC, recertification), since the OASIS questions make up only a portion of each of these comprehensive assessments. This will also help you decide where to document "look back" information for easy retrieval.

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CMS and DQA to Implement Emergency Preparedness Response System --- E-mail Addresses Requested
Bureau of Technology, Licensing and Education / Technology Services Section

Later this year, DQA expects to begin implementing a new information system being developed by the Centers for Medicare and Medicaid Services (CMS). This system, tentatively known as the Emergency Preparedness Resource Inventory, or EPRI, is designed to track the status of regulated health care facilities during emergencies, such as those created by severe flooding or other natural disasters, chemical spills, and similar situations.

EPRI will enable CMS and Wisconsin to send broadcast or targeted e-mail messages to DQA-regulated providers notifying them of emergency conditions and requesting information on their operational status, such as the number of beds available in a hospital or nursing facility, availability of electrical power, etc. Providers receiving emergency alerts and requests for status information will use an Internet connection to EPRI to update their status and provide other requested information.

In preparation for the rollout of EPRI, DQA will need to collect e-mail addresses for most of the health care providers regulated by the Division. An online survey will be created that providers will use to enter one or more contact e-mail addresses (typically those of the administrator and a designated back-up), an assigned facility identifier (such as the federal certification number or state license number), the name of the respondent, and a contact phone number. 

The provider identifier will be cross-referenced with the detailed facility records housed in DQA's licensing and certification databases to create the information that will be stored in the EPRI database. Providers can then be notified using their supplied e-mail addresses of the need for an EPRI status update.

Providers should look for and, in the near future, find a DQA memo announcing the availability of this online survey and a link to it on the main DQA webpage at:

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Wisconsin Nurse Aide Training Programs
Office of Caregiver Quality

All nurse aide training programs that were approved prior to the December 1, 2008 implementation date of Chapter DHS 129, Wisconsin Administrative Code, were terminated effective June 30, 2009.

Graduating Students

Students who completed one of these previously approved nurse aide training programs have one year from the date of training completion to successfully complete both parts of the Wisconsin nurse aide examination. If they do not successfully pass both parts of the examination in that time period, they will have to successfully complete a nurse aide training program that meets the revised nurse aide training requirements of ch. DHS 129.

New Program Requirements

Entities wishing to conduct nurse aide training after July 1, 2009 were required to submit a new application and meet all requirements of ch. DHS 129, dated December 1, 2008. These requirements include:

  1. The training program length must be a minimum of 120 hours.
  2. Of the120-hour training, 32 hours must be hands-on experience in a clinical setting.
  3. Instruction must be increased in the following areas:
  • Commonly used alternatives to restraints in accordance with current professional standards [129.07(b) 17, Wisconsin Administrative Code]
  • Recognizing the general effects of prescribed routine medications [129.07(b) 26, Wisconsin Administrative Code]
  • Recognizing the therapeutic interventions and specialized non-pharmacological pain control interventions [129.07(b) 27, Wisconsin Administrative Code]
  • Transferring clients safely and according to principles of patient care ergonomics and with proficiency in use of available equipment that is used to transfer clients. This requirement includes, but is not limited to: mechanical lifts, friction reducing devices, wheelchairs and gait belts [129.07(d) 3, Wisconsin Administrative Code]
  • Possible causes of dementia-related symptomatic behavior changes, specifically focusing on understanding behavior as an attempt to communicate unmet needs and, then, how to address the unmet need, including an understanding of how pain impacts behavior [129.07(f) 5, Wisconsin Administrative Code]
  • Ways to help a person with dementia continue meaningful involvement in his or her day, the importance of structure and routine, and the incorporation of the person's life story and past interests, routines, tastes, values, and background [129.07(f) 6, Wisconsin Administrative Code]
  • The stress involved for a client, family, and nurse aide in caring for a client with dementia and the techniques for coping with this stress; ways to address the person with dementia's core needs of having self-esteem boosted, being useful, giving and receiving love, and caring for self and others [129.07(f) 7, Wisconsin Administrative Code]

In addition to revising course syllabi and calendars, programs were required to revise course quizzes and course examinations to include questions relating to the additional topics listed in ch. DHS 129.
The Department placed increased emphasis on student attendance and required programs to submit policies that reflect that a minimum of 120 hours of class attendance is mandatory. Programs that allowed absences without establishing provisions to ensure completion of the mandatory minimum 120 hours of training were not approved. In addition to the above curriculum requirements, all training programs were encouraged to review and update their present policies and procedures as they relate to dress code, cell phone, camera phone usage, etc.

Questions? Contact the DQA Office of Caregiver Quality:

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

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DQA Numbered Memos (April, May, June 2009)

Access these memos via

or from individual providers' publications pages via

Memo No.



Providers Affected


Bureau of Assisted Living Restructuring to Four (4) Regions

As a result of the challenging financial future, effective April 1, 2009, the Bureau of Assisted Living will cease operations in the Northern Regional Office located in Rhinelander. Facilities previously assigned to the NRO will be reassigned to the WRO in Eau Claire, the NERO in De Pere, and the SRO in Madison.

Adult Day Care Centers
Adult Family Homes
Residential Facilities
Residential Care
Apartment Complexes


Carbon Monoxide Alarms New Requirements

2007 Wisconsin Act 205, created section 101.149 of the Wis. Stats., requiring installation of carbon monoxide alarms in most residential buildings that have fuel burning appliances. DHS/DQA is sending this information to effected facilities, requesting that all administrators, designated service managers, and licensees inform their staff of these new requirements.

Adult Family Homes
Community-Based Residential Facilities
Residential Care Apartment Complexes


Supervision of Licensed Practical Nurses in Methadone Treatment Programs

This memo provides clarification regarding the role of the supervising physician or registered nurse when a licensed practical nurse (LPN) administers methadone in basic and complex nursing situations in Certified Narcotic Treatment Service.

Area Administrators / Asst. Administrators
Bureau Directors
County DHS Directors
County Mental Health Coordinators
Tribal Chairpersons / HS Coordinators
Certified Mental Health and AODA
Community Substance Abuse Providers
Certified Outpatient Mental Health Clinics


Medication Cart Storage in Hospitals: Secured and Locked

In November 2006, hospital regulations related to medication security received updates that relaxed the requirements for all medications to be locked at all times. The regulations now require medications to be kept in a secure area and locked when appropriate. In February of 2008, CMS issued guidance related to locking and securing medications. The attached regulations and associated guidance include the provisions for locking and securing medications in hospitals and critical access hospitals.



Antipsychotic Medication Use for Individuals with Dementia

This memo addresses the current federal Food and Drug Administration (FDA) Public Health Advisories on antipsychotic medication use for the treatment of behavioral disorders in elderly individuals with Alzheimer's disease, dementia, or other organic brain syndrome.

Nursing Homes


Wisconsin Statutes, Section 50.36(5) Instructions and Proficiency in the Use of Automated External Defibrillators

2007 Wisconsin Act 104 was signed into law on March 14, 2008, establish-ing requirements for certain individuals to complete instruction and have current proficiency in the use of an automated external defibrillator (AED). This new law created section 50.36(5),Wis. Stats., effective September 1, 2008, establishing standards for the use of AEDs in hospitals.



Personal Protective Equipment

This memo introduces a Division of Public Health process that provides guidance for accessing and ordering personal protective equipment.
Attached are Guidelines for Access to and Ordering of Personal Protective Equipment and the Pandemic Influenza Medical Countermeasures Order Form.

Nursing Homes


Health Facility Construction Plan Reviews and Onsite Inspections

This memo provides notice of interim measures DQA has implemented to ensure a timely response to the review of construction /remodeling plans and their subsequent construction inspections.

Ambulatory Surgical Ctrs
Community-Based Residential Facilities
End Stage Renal Dialysis Facilities
Nursing Homes


Preadmission Requirements for Community-Based Residential Facilities
New Requirements Effective July 1, 2009

This memo presents guidance to Community Based Residential Facilities about their responsibility to make referrals on behalf of and to provide information to prospective residents. The information and referral requirements, often referred to as Preadmission Consultation (PAC) requirements, go into effect on July 1, 2009.

Community-Based Residential Facilities


Preadmission Requirements for Residential Care Apartment Complexes
New Requirements Effective July 19, 2009

This memo presents guidance to Residential Care Apartment Complexes about their responsibility to make referrals on behalf of and to provide information to prospective tenants. The information and referral requirements, often referred to as Preadmission Consultation (PAC) requirements, go into effect on July 1, 2009.

Residential Care Apartment Complexes


Preadmission for Nursing Homes
New Requirements Effective July 1, 2009

This memo presents guidance to nursing homes about their responsibility to make referrals on behalf of and to provide information to prospective residents. The information and referral requirements, often referred to as Preadmission Consultation (PAC) requirements, go into effect on July 1, 2009.

Nursing Homes


Discontinuing the Issuance of Annual/Biennial Certificates

The Bureau of Assisted Living, beginning July 1, 2009, will no longer routinely issue renewal certificates or send confirmation letters.

Adult Day Care Centers
Residential Care Apartment Complexes


Heat Awareness

The purpose of this memo is to introduce Heat Awareness information that was developed by Wisconsin Emergency Management (WEM) and the National Weather Service (NWS).

Ambulatory Surgery Ctrs
Adult Day Care
Adult Family Homes
Certified Mental Health and AODA
CLIA Laboratories
Community-Based Residential Facilities
End Stage Renal Dialysis Units
Facilities for the Develop-mentally Disabled
Home Health Agencies
Nursing Homes
Outpatient Rehabilitation Facilities
Residential Care Apartment Complexes
Rural Health Clinics


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DHS Administrative Rules Update
Administrator's Office

DHS 12 - Caregiver Background Checks

On September 15, 2008, the Wisconsin Administrative Rules website published the Initial Proposed Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code, Chapter DHS 12. Section 50.065(2m)(d), Wis. Stats., 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 caregiver." 

The proposed rule was revised based upon comments received from advocacy organizations, trade and professional associations, and other interested parties. The Department adopted and filed its final rules specifying those crimes for which an entity must disclose a conviction of its caregivers who are assigned to provide service in a client's personal residence. The anticipated effective date of the new rule is July 1, 2009.

For more information, you may view the final rule order on the Wisconsin Administrative Rules website at:

DHS 83 - Community Based Residential Facilities

On April 1, 2009, revisions to Wisconsin Administrative Code, Chapter DHS 83 went into effect. The revised rule contains several changes that CBRF providers need to be aware of, including changes to the administrator qualifications, training requirements, medication administration requirements, and sprinkler system requirements for small class C facilities. The rule may be viewed at:

Staff from the Bureau of Assisted Living has developed industry training on the new requirements in DHS 83 for CBRF staff. The training is presented in four (4) modules and includes valuable, downloadable handouts that provide information on how the new rule will affect your facility. The training is web-based and available on the Wisconsin Department of Health Services website. The training modules and handouts can be accessed at

Please watch for important memos related to the implementation of DHS 83. The link to the CBRF memos can be found at:

DHS 85 - Non-Profit Corporation as Guardian

On September 19, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter DHS 85, Non-profit Corporation as Guardian. Through this initiative, the Department proposes to make the rule reflect current standards of practice, recognizing the increase in the number of adults in need of guardianship and the increase in the complexity of their needs.

An Advisory Committee, including advocates, providers, registers in probate, and County adult protective services staff, met and reviewed proposed rule language and made recommendations for change. The Department revised the proposed rule based upon comments from the Advisory Committee. The proposed Rule Order is currently under review by the DHS Office of Legal Counsel. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at:

DHS 124 - Hospitals

On April 1, 2005, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter DHS 124. The Department is planning to update Chapter DHS 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.

The Department asked representatives from a large number of trade and professional associations, hospitals, and other interested parties, to review proposed revisions to the rule and make recommendations for change. The Department is reviewing their recommendations and preparing a revised draft of ch. DHS 124 for further review by stakeholders.

On May 31, 2009, the Wisconsin Administrative Register published a Statement of Scope to amend Chapter DHS 124. The Department proposes to update Chapter 124 to establish standards for satellite emergency departments, to cross-reference applicable provisions relating to anatomical gifts under s. 157.06 (14m), Wis. Stats., to specify standards relating to forfeiture assessment for violations of s. 50.375, Wis. Stats., and to include requirements under s. 50.36 (5), Wis. Stats., relating to training and proficiency of hospital staff in the use of automated external defibrillators. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at:

DHS 131 - Hospices

On December 15, 2008, the Wisconsin Administrative Rules website published a Statement of Scope of proposed rules to revise Chapter DHS 131, Hospices. The Department proposes to revise ch. DHS 131 to align the rule with revised federal Medicare regulations, to eliminate outdated regulations, and to reflect current professional standards of practice.

The Department has asked the Hospice Organization and Palliative Experts (HOPE) of Wisconsin, hospices, and hospice consumers to participate in revising ch. DHS 131. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at:

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CMS Survey & Certification Letters (April, May, June 2009)

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

S&C No.



Providers Affected


Issuance of Revisions to Interpretive Guidance at Several Tags, as Part of Appendix PP, SOM

Revisions have been made concerning Quality of Life and Environment. Included is a training document with speaker notes for CMS Regional Offices ROs and State Survey Agencies to use to train surveyors in this revision to the SOM.



Expansion of Moratorium Exception on Classification of Long Term Care Hospitals or Satellites

The American Recovery and Reinvestment Act (ARRA), enacted 02/17/09, expands exceptions to the 3-year moratorium on LTCH or LTCH satellites previously enacted in the Medicare, Medicaid, and SCHIP Extension Act
(MMSEA) (Pub. L. 110-173). The new exception permits an increase in the number of beds when the bed increase was authorized under a Certificate of Need (CON) issued within a specified timeframe. CMS is amending the guidance issued in S&C-08-26 to reflect this statutory change. CMS Regional Offices will determine whether a facility qualifies for the new exception.

Long Term Care Hospitals
or Satellites


Survey and Certification Issues Related to Swine Flu Outbreak

Human cases of swine influenza A(H1N1) have been identified in several States in the US, as well as internationally. Charles Johnson, Acting Secretary of the US DHHS, declared that a public health emergency exists nationwide. In emergencies where certain conditions precedent have been met, the Secretary of may invoke
waiver authority under Section 1135 of the Social
Security Act and delegate to CMS the authority to waive or modify certain survey and certification requirements.



Release of Form CMS-2567 (Statement of Deficiencies) by State Survey Agencies (SAs)

This memo reiterates current law and regulations and guidance contained in Chapters 3 and 7 of the CMS State Operations Manual that involve the release of the survey findings as reflected in the Statements of Deficiencies, commonly referred to as the 2567.



Clinical Laboratory Improvement Amendments (CLIA) -- Impact of A/H1N1 Swine Flu on CLIA Operations

CMS has agreed to delay routine surveys of State PHLs temporarily, unless there is immediate jeopardy to patient health and safety, until May 15, 2009, at which time CMS will re-assess this determination. Suspended Influenza Proficiency Testing (PT) for One Event: CMS has notified the PT Programs with viral antigen modules which contain testing for influenza A that these should be suspended until May 15, at which time this decision will be re-assessed. Laboratories subject to PT for viral flu testing have discretion regarding their participation for this event.

CLIA Laboratories


H1N1 Flu State Survey Agency Guidance and Provider Tracking Tools

To assist surveyors to observe signs of the H1N1 flu virus infection, and proper facility etiquette, a guidance document has been developed in collaboration with CDC. To assist in reporting any impact to State survey
activities and providers that
have been affected by the H1N1virus infection to the CMS Regional Office, a tracking tool has also been developed.



State Operations Manual (SOM) Appendix L, Ambulatory Surgical Centers (ASC) Comprehensive Revision

New ASC Conditions for Coverage (CfCs) take effect May 18, 2009. SOM Appendix L has been revised: Part 1, Survey Protocol has been added. Interpretive Guidelines have been extensively updated to reflect the new and revised CfCs and provide more detailed guidance for existing CfCs. ASPEN Tags for ASC surveys have been revised and renumbered.

Ambulatory Surgical


One-Time Cash Benefit to Nursing Home Residents

The Recovery Act provides for a one-time cash benefit of $250 to certain eligible individuals who receive a Social Security benefit, Railroad Retirement pension, Veterans Administration disability pension, and Supplemental Security Income (SSI). The payments will begin in May of 2009 and be distributed by check or electronic transfer to eligible beneficiaries by 06/04/09.

Nursing Homes


Nursing Home Requirements for Food Procurement, Self Determination, and Participation

This memorandum clarifies that 1) the language at 42 CFR 483.35(i), Tag F 371 'Procure food from sources approved or considered satisfactory by Federal, State or local authorities' is intended solely for the foods procured by the facility. A
revision has been made to the interpretive guidelines at F371 to further clarify this
intent; 2) Foods accepted by residents from visitors, family, friends, or other guests are not subject to the regulatory requirement at F 371; and 3) Residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices at 483.15, F 242, Self Determination and Participation.

Nursing Homes


One-time Cash Benefit to
ICF/MR Clients

The American Recovery and Reinvestment Act of 2009 provides for a one-time cash benefit of $250 to certain eligible individuals who receive a Social Security benefit, Railroad Retirement Pension, Veteran's Administration disability pension and Supplemental Security Income (SSI). Many ICF/MR clients may be eligible for this one-time cash benefit.



Policy Regarding Unannounced Surveys

This memorandum reiterates current policy that all surveys must be unannounced for all providers and suppliers, except for standard surveys of Clinical Laboratory Improvement Amendments (CLIA) laboratories and other limited exceptions.



June 30, 2009 Healthcare Associated Infections Professional Stakeholder Meeting

On 06/30/09, the DHHS plans to gather key partners in the Action Plan to Prevent Healthcare Assoc-iated Infections to provide updates on the initiative and engage in a dialogue about potential next steps. The 06/30/09 meeting is in Washington, DC.



Recovery Act Ambulatory Surgical Center Healthcare Associated Infection Prevention Initiative

CMS and States will improve quality assurance of ASCs during FY 2009 and FY 2010 by implementing a new survey process to promote better infection control practices.

Ambulatory Surgery Ctrs.


Use of Civil Money Penalty (CMP) Funds by States and Reporting of CMP Funds Returned to the State

The purpose of this memorandum is to clarify that States may direct collected CMP funds to entities other than nursing homes as long as funds are
used in accordance with statutory intent; share innovative practices that States may want to consider when making decisions about how CMP funds can be directed and used to improve the quality of care and life for nursing home residents; and announce CMS will consider reporting CMP amounts that have been returned to each State.



North Dakota and Minnesota Flooding Public Health Emergency and 1135 Waiver Termination

The Secretary has determined that the Public Health Emergency no longer exists in North Dakota and Minnesota and the 1135 waiver authority is ending concurrently with the termination of the public health emergency.



The Secretary has determined that the Public Health Emergency no longer exists in North Dakota and Minnesota and the 1135 waiver authority is ending concurrently with the termination of the public health emergency.

Announces the release of the Evaluation of the Quality Indicator Survey (QIS) and the posting of the Executive Summary on the CMS Web site. Outlines Action Plan for future QIS Evaluation Initiatives.



Content contact: Gina Bertolini
Phone: (608) 266-6691


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Last Updated: May 28, 2014