Quarterly Information Update

October 2007

PDF Version of this month's Quarterly Update (PDF, 72 KB)

• Focus 2008 Conference

• New NERO AL Director

• New OASIS Submission Specs

• Teleworkers' Phone Numbers

• APS Listserve Notification System

• Patient Safety

• Life Safety Code Reminder

• Transplantation Program Applications

• Home Health Online Training Course

• Reportable Death Review Process

• Upcoming DQA Training Events

• CMS Webcasts

• Latest DQA Memos

• Latest CMS S&C Letters

• Winter Safety

• Post Construction Questionnaire

• Administrative Rules Update

Focus 2008 Conference

Save the Dates: Mark your calendars for the Division of Quality Assurance FOCUS 2008 conference which will be held on Wednesday, August 6, 2008. This conference is for staff from Assisted Living Facilities, Nursing Homes, Facilities Serving People with Developmental Disabilities and the Division of Quality Assurance. The pre-conference date is Tuesday, August 5, 2008. Watch for further details in future Quarterly Updates.

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New Bureau of Assisted Living Director in the NERO

It is our great pleasure to announce that Laurie Arkens has been promoted to the Assisted Living Regional Director for the NERO.

Laurie brings excellent skills and knowledge to this position, including 6 years of supervision and management experience working for a large assisted living and residential services agency serving adults and children with developmental disabilities, and over 17 years of state service. Laurie has excelled in her various positions working for the Division of Quality Assurance, including her years as a licensing specialist and, most recently, as a training consultant with the Bureau of Technology, Licensing and Education. In her role as training consultant Laurie has been an integral member of a team that has developed and implemented a number of innovative initiatives that have created an efficient and effective regulatory agency, has helped improve the lives of Wisconsin citizens living in assisted living facilities and has increased national attention to Wisconsin.

Please join me in welcoming Laurie to this critical position in the Bureau of Assisted Living.

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New OASIS Data Submission Specifications

CMS has developed a new Version 1.60 of the OASIS data specifications to incorporate changes that were mandated by the Medicare PPS proposed rule that was published in the Federal Register on May 4, 2007. The primary purpose of these changes is to replace and add OASIS fields to support a new version of the HHRG grouper. The implementation of Version 1.60 is contingent upon the reason for assessment (the value of OASIS item M0100):

• All assessments with a reason for assessment of 04 or 05 and completion dates (M0090) on or after 12/27/2007 must conform to the Version 1.60 specifications.  Assessments with a reason for assessment of 04 or 05 and completion dates on or before 12/26/2007 must conform to the Version 1.50 specifications (or to previous versions, if appropriate).
• All assessments with a reason for assessment of 01, 03, 06, 07, 08, or 09 and completion dates (M0090) on or after 01/01/2008 must conform to the Version 1.60 specifications.  Assessments with a reason for assessment of 01, 03, 06, 07, 08, or 09 and completion dates on or before 12/31/2007 must conform to the Version 1.50 specifications (or to previous versions, if appropriate).

Home health agencies should work with their software vendors to ensure OASIS software programs are updated to incorporate these changes. The draft Version 1.60 of the OASIS data specifications are available at: https://www.qtso.com.

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Teleworker Phone Numbers

DQA is in the process of eliminating land lines for survey staff. Once this process has been completed, you will need to contact those individuals using their state-issued cell phones. During this transition, the land line number assigned to the surveyor will direct the caller to his/her cell phone number or the regional office. After the transition period, callers will need to call the regional office main number to obtain a specific surveyor's cell phone number.

The land lines will be removed starting with the Southeastern Regional Office (Milwaukee) the week of October 8th. We will then eliminate land lines, in order, for the Northeastern Regional Office (Green Bay), Western Regional Office (Eau Claire), and Northern Regional Office (Rhinelander). The Southern Regional Office (Madison) had their land lines removed after their recent move.

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APS Listserve Notification System

As of August 15, 2007, the Bureau of Aging and Disability Resources, Adult Protective Services will have a listserv notification system for all correspondence. All communication will be sent via the listserv. If you are interested in receiving electronic notification of policy-related information, numbered and informational memos (SafetyNetworks) for the Adults-at-Risk Services (APS), sign-up at http://www.dhs.wisconsin.gov/aps/Pros/listserv.htm. See DDES INFO MEMO 07-09 at http://www.dhs.wisconsin.gov/dsl_info/InfoMemos/DDES/CY2007/InfoMemo200709.htm  for more information about the listserv. For additional information on the Wisconsin Elder Adults/Adults-at-Risk and Adult Protective Service Response Systems, please see the Department's website at http://www.dhs.wisconsin.gov/aps/.

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Patient Safety

The Pennsylvania Patient Safety Authority, established in 2002, offers the benefit of lessons learned through their mandatory statewide Pennsylvania Patient Safety Reporting System (PA-PSRS) on their website at: http://www.psa.state.pa.us/psa/site/default.asp 

More than 400 healthcare facilities subject to Pennsylvania reporting requirements are submitting reports through PA-PSRS, making Pennsylvania the first state in the nation to require the reporting of both actual events and "near misses."

The Patient Safety Authority has developed and posted a fascinating interactive tool to assist providers in identifying environmental hazards, which uses real-life examples to illustrate and amplify. Entitled "Behavioral Health Patient Room: Common Hazards," this graphic can be viewed at: Common Hazards

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Life Safety Code Reminder

The topic of sprinkler coverage, or lack there of, comes up frequently whether one is discussing upcoming nursing home regulations or which provisions apply to hospitals without full sprinkler coverage.

So, it seems like a good time to run down the restrictions that the 2000 Life Safety Code (LSC) details under Chapter 19 for healthcare occupancies that are not fully sprinkler protected. Chapter 19 covers hospitals, nursing homes, and limited care facilities; and it doesn't mandate that these existing buildings have full sprinkler protection, although facilities may choose to install it.

For existing facilities under Chapter 19, the LSC provides the following 14 restrictions for facilities that are not fully sprinkler protected:

1. No combustible construction types (19.1.6)
2. Decreased means of egress capacities (19.2.3.2)
3. Shorter travel distances to an exit (19.2.6.2.1 and 19.2.6.2.2)
4. Gift shop restrictions on size or separation from a corridor (19.3.2.5)
5. Interior finish flame-spread testing requirements (19.3.3.2 and 19.3.3.3)
6. Smaller waiting areas allowed open to the corridor (19.3.6.1)
7. Fire rated corridor wall construction (19.3.6.2.1)
8. Corridor wall window size limitations and fire-resistance rating (19.3.6.2.3)
9. Corridor door construction restrictions and vision panel size limitations (19.3.6.3.7 and 19.3.6.3.8)
10. Corridor wall pass-through size limitations (19.3.6.5)
11. Smoke barrier dampers are required (19.3.7.3)
12. Kitchen hood extinguishing system connection to the fire alarm (19.3.4.2)
13. Upholstered furniture and mattress testing requirements (19.7.5)
14. Additional smoke detection in resident rooms and common areas such as dining, activity, corridors, and other meeting spaces where residents gather. Reference: CMS memo S&C 05-25 for further details.

Chapter 18 in the LSC already mandates full sprinkler protection in newly constructed healthcare occupancies.

Existing facilities, planning to add sprinkler protection to obtain full coverage, will benefit from not having to meet the 14 conditions listed above. Remember to submit plans and specifications to the Department for plan review prior to construction to ensure full credit for all benefits due your facility.

Sprinkler protection is the single most effective fire protection feature that can be installed in a health care facility to reduce the chances of death and dollar loss.

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Transplantation Program Applications

Reminder: Transplantation Programs - Applications for approval are due by December 26, 2007

The final rule published on March 30, 2007, establishes Conditions of Participation for organ transplant centers and places Medicare-approved transplant centers under the survey and certification enforcement process for providers and suppliers.

The rule went into effect on June 28, 2007. Medicare-approved transplant centers have until December 26, 2007, to apply for approval under the new Conditions of Participation.

On Tuesday, October 16, 2007, 2:00 p.m - 3:00 p.m, Eastern Daylight Time (EDT), the Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum to give an overview of the latest requirements for transplant centers seeking Medicare approval to perform organ transplants. To participate in this special forum, please register on the CMS website at: http://registration.intercall.com/go/cms2. Upon registering, you will receive a confirmation email containing further participation information. The deadline for registration is 2:00 p.m EDT, October 12, 2007.

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DQA Home Health Online Training Course Available Late Fall 2007

The Division of Quality Assurance is excited to announce that an interactive online Home Health Training course will be accessible later this fall to Home Health Agencies and organizations, and DQA survey staff. Past experience has shown us how important it is for both home health agency staff and DQA staff to have a solid understanding of the regulations affecting home health. This online opportunity is all about helping to build a foundation of understanding about the regulations. Individuals that take the online session will learn about the different survey types and Conditions of Participation (CoPs) important to home health providers and surveyor. The course will also serve as a foundation for staff that needs to develop strategies for determining compliance with federal regulations.

The course will be available online at personal computers via Internet access for a small registration fee. It will be accessible to individuals that have registered 24 hours a day, 7 days a week to meet the needs of the user. Additional information on the online training course, how to register, and the registration fee will be provided as it becomes available.

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Revised Reportable Death Review Process for Outpatient Treatment Providers

• DQA institutes "event analysis" in lieu of outpatient clinic suicide investigations.
• Client death reporting is still required for all suicides and other reportable causes.

The Division of Quality Assurance, Behavioral Health Certification Section (DQA/BHCS), has revised the review process of "reportable" adult deaths in outpatient treatment clinics. DQA has been investigating deaths of active patients in mental health and substance abuse treatment programs since the legislature passed Act 336 in 1989. The Act amended Chapters 48, 50, and 51 to require treatment providers to promptly report deaths attributed to suicide, restraints, seclusion, or the effects of psychotropic medications; and assigned the Department of Health and Family Services the responsibility to investigate those patient deaths.

The intent of the law is to protect clients/patients and assure that treatment is delivered in compliance with state statute and administrative code. Because of an increase in the number of certified mental health and substance abuse programs and providers, and their improved reporting, the number of deaths reported has risen from under 50 to over 200 a year. The ability of the Behavioral Health Certification Section to complete timely on-site investigations has declined as deaths are prioritized for review. Delays are problematic for clinics that have already completed their own case reviews and processed the grief of losing a patient.

Patient suicide represents over 95% of reportable deaths, with 80% of those cases coming from outpatient treatment clinics. Past investigations reveal that mental health outpatients who commit suicide are typically found to have been receiving adequate or good care. Compliance deficiencies are not commonly found and, if present, are often unrelated to the client death. While non-compliance issues are uncommon, investigator recommendations for quality improvements are frequently made as a result of the on-site investigation.

In response to these cumulative findings, DQA has amended the investigative process so that internal health care reviews replace on-site DQA staff investigations of adult suicides only from outpatient mental health and outpatient substance abuse treatment clinics. The internal health care reviews are exempt from external purview, based upon state statute ch.146.38, confidentiality of health care services review. This revised process will enable clinics to more quickly conduct event analyses and implement quality improvement plans. As such, the process becomes proactive and directed toward improved services and treatments while replacing unproductive, redundant, or untimely reviews of past events.

Client/patient death reporting remains the law and is still required of all certified and licensed providers. Following the death report, all non-outpatient provider deaths will be investigated in accordance with current practice. It is anticipated that these DQA/BHCS reviews will be timelier and focused and, hence, less disruptive and more effective.

Only outpatient treatment providers will be sent the Report and Summary of Client/Patient Death, Quality Improvement Event Analysis Form. The form provides instructions for making the event analysis and for collecting the action plans for quality improvement, where warranted. The process brings together staff members who had direct contact with the deceased to review and discuss the case and to identify opportunities for clinical and systemic improvements. The provider then determines an action plan for quality improvement, identifying who is responsible and when it will be implemented. The BHCS licensing specialists will review and confirm the action plans at the next regularly scheduled program review.

The Department retains the authority to investigate any reportable death. DQA/BHCS will continue to investigate all deaths of especially vulnerable individuals such as minors, community support program clients or inpatients, and patients served in other community-based or residential care settings. Investigations will occur in programs where there are a series of deaths, when there are common factors, when there is a complaint, or where the death takes place in the public arena.

This change, though limited, affects the majority of all deaths reported. We encourage outpatient treatment providers to actively support and participate in the event analysis as they conduct systemic health care reviews focusing on quality improvements. We welcome your feedback in making a smooth transition to this process.

If you have questions on this process or would like to review the Report and Summary of Client/Patient Death, Quality Improvement Event Analysis form, please contact Rick Ruecking, BHCS, rueckrb@hfs.state.wi.us, (608) 261-0657; fax 261-0655.

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Upcoming Division of Quality Assurance Educational Events

Check out the Division of Quality Assurance online educational opportunity information website at http://www.dhs.wisconsin.gov/rl_DSL/Training/index.htm for additional information on upcoming events, dates, locations, registration, and web cast viewing links. Below is a list of upcoming opportunities.

*Webcasts are available for online viewing up to one year after the date of the live broadcast. For handouts and the online link to view a webcast please go to: http://www.dhs.wisconsin.gov/rl_DSL/Training/index.htm.

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CMS Webcasts

Listed below are the CMS webcasts that were produced from July-Sept. 2007. They will be available for 1 year after the date of broadcast. You may access these webcasts at: http://surveyortraining.cms.hhs.gov/

8/3/07 Physical Restraint Use in Nursing Homes: The Exception Not the Rule,
Part 1
8/17/07 Physical Restraint Use in Nursing Homes: The Exception Not the Rule, Part 2
8/31/07 Physical Restraint Use in Nursing Homes: The Exception Not the Rule, Part 3
9/14/07 From Institutional to Individualized Care Part 4: The How of Change
9/28/07 Mental Illness in Nursing Homes

FUTURE WEBCASTS

A series of 3, one-hour webcasts:

Identifying and Responding Appropriately to Resident-to-Resident Abuse, including Sexual Assault, in Facility Settings

Audience: Health care staff that work in Assisted Living Facilities, Nursing Homes, Facilities Serving People with Developmental Disabilities, Home Health Agencies, Hospices, Hospitals; Ombudsmen; DQA surveyors, investigators, and program staff.

Content:
Webcast #1:
Occurrence/examples of incidents in Wisconsin
Definition of resident-to-resident abuse - including: types of abuse, situations involving competent vs. incompetent individuals, and consensual vs. non-consensual encounters
Presenters: Paul Peshek, DQA, and Ellen Henningsen, Attorney at the Coalition of Wisconsin Aging Groups (CWAG)

Webcast #2:
Resident assessment and care plans
Intervention techniques, prevention strategies, and victim-centered services
Presenters: Joanne Powell and Susan Murphy, DQA, and Julie Button, Ombudsman

Webcast #3:
Legal ramifications beyond DQA (focus on when the abuse is a crime and the need for law enforcement involvement)
Facility responsibility to take action (focus on conducting a thorough investigation)
Policies/Procedures (what should be included)
Reporting requirements
Presenters: Linda Dawson, Attorney at Reinhart, Boerner, Van Deuren; and Cremear Mims and Shari Busse, DQA

Watch for information announcing when the webcasts will be available for viewing.

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Latest DQA Numbered Memos

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/.

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Latest CMS Survey & Certification Letters

Listed below are selected Survey and Certification (S & C) Letters distributed by CMS during the last quarter. Titles pertaining only to state agency operations are omitted. If you have questions about individual letters, contact Jan Eakins of DQA at (608) 266-2055, or e-mail her at: eakinjl@dhfs.state.wi.us. Please note that the CMS Internet site for all S & C memos is: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

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Winter Safety

Winter weather is soon approaching and exposure to cold temperatures can be serious or life threatening. Infants and the elderly are particularly at risk for hypothermia (body temperature of 95 degrees or lower) and frostbite. Other susceptible persons include those with certain health conditions, persons with impaired cognition or judgment, and persons who remain outdoors for long periods.

Preventive action is the best defense against weather-related health problems. Providers should identify those persons at risk for wandering and develop a corresponding care or service plan, as well as an emergency plan.

Some further preventive measures include ensuring that individuals wear appropriate winter clothing, encouraging intake of balanced meals and warm non-alcoholic beverages, maintaining heating systems in good working order, eliminating drafts, and having an emergency plan in the event of power outage. All staff should also be familiar with symptoms of cold-related illness and initial treatment.

Additional information is available from the Centers for Disease Control and Prevention at: http://www.bt.cdc.gov/disasters/winter/guide.asp

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Pilot: Post Construction Inspection Questionnaire For Hospitals

As part of the Division of Quality Assurance (DQA) ongoing quality improvement processes, the Division would like to measure providers experience with the on-site engineer construction inspections. Results from this pilot will provide an opportunity for DQA to address improvements in the oversight process, expand providers knowledge and understanding of the process and identify whether training is needed in hospital building requirements.

DQA is committed to providing you with a beneficial and informative interaction during construction inspections. Results will be tallied by our quality assurance staff within the Bureau of Health Services. Completing the survey questionnaire is voluntary. We strongly encourage you to designate your facility plant manager, or other personnel who have direct interactions with our staff, to complete and return the questionnaire to DQA. Only one evaluation is to be sent in.

The pilot will begin November 1, 2007, and end February 29, 2008. Engineers will provide hard copies of the questionnaire when conducting construction inspections. Providers may also access the questionnaire at the following link:
http://www.dhs.state.wi.us/rl_DSL/PlanReview/index.htm

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Administrative Rules Update

HFS 83 - Community Based Residential Facilities

The HFS 83 Rewrite Workgroup completed the initial draft of the proposed rules for Chapter HFS 83. The goal of the workgroup was to eliminate excessively prescriptive language and improve readability and organization. The proposed rule clarifies medication administration requirements and revises staff training standards, establishing a more cost-effective system for providers. Currently, the proposed rule is under review by the DHFS Office of Legal Counsel. 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, HFS - 88 Adult Family Homes, HFS 89 - Residential Care Apartment Complexes, HFS 132 - Nursing Homes, HFS 134 - Facilities for the Developmentally Disabled

On December 15, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapters 83, 88, 89, 132 and 134 relating to involuntary administration of psychotropic medication. 2005 Wisconsin Act 264 created s. 50.02 (2)(ad), Wisc. Stats., which directed the Department to promulgate rules that require the above named facilities to provide information to determine a facility's compliance with s. 55.14, Wisc. Stats. An Advisory Committee met and reviewed the proposed rule language drafted by Department staff and provided comments. The final rulemaking order was filed with the Revisor of Statute Bureau on September 4, 2007. The anticipated effective date of the rule is November 1, 2007. 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 to 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 regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements. 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 March 31, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend 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. An advisory committee, including advocates, educators, association representatives, workforce development specialists, and representatives from private industry, meets regularly to review the proposed revisions to the rule and make changes, as necessary. 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 132 - Nursing Homes

On September 4, 2007, revisions to Wisconsin Administrative Code Chapter HFS 132 went into effect. The revised rule eliminated rules that were outdated or overly prescriptive or were essentially duplicated in Chapter 50, Wisc. Stats. or in the Wisconsin Commercial Building Code or federal nursing home regulation. Two important additions were made to the rule. Section HFS 132.16 creates a Quality Assurance and Improvement committee composed of representatives from nursing homes, advocates, staff from the Department, and representatives from other interest organizations. The committee will distribute funds to facilities that have submitted innovative, cost effective proposals for improving the operations of a nursing home and the quality of life for residents. Section 132.12 (4)(b) was amended to require applicants for nursing home licensure to disclose information to the Department regarding past regulatory compliance and financial history in the operation of a health care facility. You may view the rule on the Wisconsin Administrative Rules website at: https://health.wisconsin.gov/admrules/public/Home

HFS 133 - Home Health Agencies

The HFS 133 Rewrite Workgroup, working with the advisory committee (including providers, consumers, and association representatives) has completed the draft of the proposed rules for Chapter HFS 133. The goal of the committee was to make the rule consistent with federal regulations and to reflect current terminology and practice. Public hearings were held on July 18 in Eau Claire and on July 19 in Waukesha. The final rulemaking order was filed with the Revisor of Statutes Bureau on October 1, 2007. The anticipated effective date of the rule is December 2, 2007. 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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Last Updated:  October 07, 2011