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DQA Quarterly Information Update

October 2009

PDF Version of this month's Quarterly Update (PDF, 122 KB)




  • FOCUS 2009 Conference - October 21, 22
  • OASIS-C Trainings - November


Department Approved Assisted Living Administrator Course
Bureau of Assisted Living

On April 1, 2009, with implementation of the new administrative rule, DHS 83, the qualifications for Community-based Residential Facility (CBRF) administrators were significantly revised. Per DHS 83.15(1)(c) and (d), an individual can be a CBRF administrator if he/she has the following qualifications:

  • A bachelor's degree in a field other than health care from an accredited college and successful completion of a department-approved assisted living administrator training course.
  • At least two years experience working in a healthcare-related field having direct contact with one or more of the client groups identified under s. DHS 83.02(16) and successful completion of a department-approved assisted living administrator training course.

Please review the entire DHS 83.15, Administrator Section, for additional acceptable qualifications.

The Bureau of Assisted Living management team has been working to develop criteria for a department-approved assisted living administrator training course. It is anticipated that the outline for a department-approved curriculum, the criteria for course trainers, and applications for both curriculum and trainer approval will be available soon. Please watch for the release of this information via Listserv in the near future.

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Be More Green
Bureau of Assisted Living

Kermit the Frog was wrong --- the Bureau of Assisted Living (BAL) has learned that it is easy being green! In September 2008, BAL kicked off a campaign, including fun contests, to encourage staff to come up with creative ways to streamline operations and to conserve energy and other resources. 

In addition to decreasing overhead costs, many of the ideas will also help to save our planet. Submissions are reviewed at a management team meeting and winners are notified at the BAL all-staff bi-monthly meetings that are held via Microsoft Live Meeting. 

BAL is able to award the winners with fabulous energy saving prizes, including Energy Star compact fluorescent bulbs and foam outlet insulators. Also included is a helpful booklet of 101 money and energy saving tips supplied by WE Energies, an electric and gas utility provider for portions of Wisconsin.

Another objective of this effort is to share these ideas with other regions and to see them further implemented. Some of the great ideas that have already been implemented are:

  • Turn off lights in areas where staff are not working.
  • If using light fixtures that use three long fluorescent tubes, remove the center tube and install brighter, more efficient tubes in the other two ballasts. No one will even notice the difference!
  • Turn off computers when you leave for the day and when you leave your desk for extended periods of time during the day.
  • Make "file copies" on two-sided paper to save paper and storage space.
  • Streamline the renewal process for over 3,000 facilities to eliminate extraneous paper work.
  • Replace paper processes with electronic processes.
  • Add an automatic "tag line" on outgoing e-mails: "Please consider the environment before printing this e-mail."
  • Ensure that your recyclables are being recycled. One regional office realized that their "recycling" bins were being emptied into the regular garbage and arranged for a local company to remove their recycling (non-confidential) for no cost.
  • Eliminate hand-outs at meetings. At management team meetings, BAL no longer makes copies of meeting materials; instead, materials are sent electronically to participants and viewed using a laptop and projector.

In addition to the on-going "Be More Green" contest for staff, the Bureau has collaborated with We Energies. A representative of WE Energies, Paul Van DeSand, attended the Assisted Living Forum in January 2009 and presented information on various Energy Programs available to assisted living facilities that would allow them to save money and conserve natural resources. 

Because this initial meeting generated significant interest among providers, a follow-up meeting was held in July between the assisted living associations, WE Energies, and representatives from Rapid Improvement Associates (who demonstrated an innovative web-based energy stewards' platform).

We encourage readers to join the Bureau of Assisted Living in "becoming more green." Helpful tips to improve your energy efficiency and information on various residential and business programs are available at:  and

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Walworth and Milwaukee Counties to Have Managed Care
Administrator's Office

Effective October 1, 2009: Walworth County

Effective November 1, 2009: Milwaukee County

  • Persons with a disability under the age of 60 are referred to the Disability Resource Center of Milwaukee County.
  • Persons with a disability who are 60 or older are referred to the Aging Resource Center of Milwaukee County.

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Preadmission Consultation (PAC) Requirements for Providers
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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RAI / MDS 2.0 Coding Clarifications
Bureau of Technology, Licensing and Education / Technology Section

Influenza Vaccinations in Section W

Only the seasonal flu vaccine is coded in Section W. The H1N1 vaccine should be documented in the clinical record, but not coded in Section W of the MDS.

The flu season begins when the vaccine is available and, if facilities are giving the vaccine in September, they can code it in Section W2a1 for those assessments with an ARD beginning October 1. Only those assessments with an ARD beginning October 1 and continuing through June 30 are to have the W2 field completed. 

For example, if a resident received the flu vaccine in September and their current MDS has an ARD of 09/28/09, the vaccination information would not be coded on this MDS. Any subsequent MDS assessments completed with an ARD on or after 10/01/09 will capture that information.

Suspected Deep Tissue Injuries

Currently there is no way to document a suspected deep tissue injury (SDTI) on the MDS 2.0 at item M1. Facilities should refer to the RAI Manual definitions for each stage and code what is known, not what is suspected. Code is based on the observed appearance of the area and whether or not it matches any of the definitions of the various stages described in the manual. The facility should also document in the resident's clinical record if they suspect the resident has a deep tissue injury.

SDTIs can be coded on the MDS 2.0 at I3. Effective October 1, 2008, the ICD9CM codes were updated. As part of this update, there are new codes for different ulcer stages, including suspected deep tissue injury and unstageable. In addition, deep tissue injuries are a projected part of the MDS 3.0 coding.

CMS has stated that Survey and Certification memos clarifying the coding of Section W and SDTIs in the MDS 2.0 will be forthcoming. These memos can be accessed at:

MDS 3.0

MDS 3.0 is on schedule and CMS is indicating that final drafts of both the MDS form and Manual, along with other key documents, will be released starting in October 2009. Background information regarding MDS 3.0, as well as links to these documents, can be accessed at the CMS website. Facilities should check this site regularly for updates and newly released documents.

Facilities with questions about the information in this article should contact:

Peg Katz, MDS Education Coordinator


Chris Benesh, MDS Automation Coordinator

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Home Health: OASIS-C is Finalized
Bureau of Technology, Licensing and Education / Technology Section

The Centers for Medicare and Medicaid Services (CMS) announced in late July that CMS had received an official three-year approval of the Outcome and Assessment Information Set, Version C (OASIS-C) document from the Office of Management and Budget, extending through July 31, 2012. In addition, CMS announced that OASIS-C will become effective for all Medicare-certified Home Health Agencies (HHAs) on January 1, 2010. HHAs must collect OASIS dataset information on their patients in order to participate in the Medicare program.

The final version of OASIS-C was published on the CMS website in August 2009; the July 2009 version had an error in item M1330, so be certain to select the corrected version at the bottom of this CMS webpage, as well as a detailed crosswalk from OASIS-B1 to OASIS-C: 

OASIS-C is the first major update to the OASIS dataset since it was introduced in 1999. There are significant revisions to existing elements, elimination of some elements, and the addition of new elements that are capable of capturing new structure, process, and outcome measure 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, which are endorsed by the National Quality Forum (NQF).

NQF has been working to 'globally harmonize' reporting measures across all post-acute health care settings and has endorsed 20 homecare quality measures toward this effort with four additional measures pending. 

The endorsement of this set of standards that measures the quality, safety, and 'patient experience' of care delivered in the home closely aligns with the National Priorities Partnership to transform the healthcare system. CMS anticipates public reporting on the new measures will begin in Spring 2011.

View the April 2009 NQF press release which includes the 20 endorsed HHA quality measures. (Exit DHS)

OASIS-C Trainings

Wisconsin has scheduled three OASIS-C training sessions for HHAs in early November:

  • November 4th in Eau Claire
  • November 10th in Oshkosh
  • November 12th in Madison

This day-long program will provide participants with information related to the new OASIS-C dataset and its use, including:

  • OASIS changes effective January 2010
  • Review of OASIS-C items
  • Introduction of new Process Measures
  • Application of OASIS-C to Quality Reports

Additional information can be found in the training brochure, along with an online registration process on the DQA training page at:

CMS will also be offering a free three-part series of national Medicare Learning Network (MLN) 'Train-the-Trainer' teleconference calls on a variety of topics related to OASIS-C implementation on October 22, November 12, and December 8. Presenters include members of the team of clinical consultants that assisted CMS with the development of the new OASIS-C dataset. Calls will be recorded for those unable to participate, and options will include listening to the call or reading a transcript. Learn more or sign up for MLN e-mail updates at:

New OASIS Resources

To assist HHAs in finding OASIS-related information that is currently available across multiple websites, DQA has developed a new OASIS Resource web-page that contains the links to many of the OASIS resources HHAs might need --- a kind of 'one-stop-shop' for OASIS information. This website will be continually updated to reflect the most current OASIS resources available online. The DQA OASIS Resource webpage is at: 

CMS has re-written the OASIS Implementation Manual to correspond with OASIS-C. Along with many other new or updated OASIS-C related materials, the new manual, "OASIS-C Guidance Manual," will be posted online at:

The original OASIS Implementation Manual will be archived online for reference, which may be especially helpful for new Medicare-certified HHAs. The new Guidance Manual contains the updated item-by-item tips for completing OASIS-C questions that HHAs have come to rely upon, along with other essential information. OASIS Q&As on the QTSO website (noted above) will be updated to reflect the new OASIS-C 'M-numbering' dataset questions.

Future Plans

CMS plans to release new Wound, Ostomy, and Continence Nurses (WOCN) guidance related to the new OASIS-C wound questions, when that becomes available. Also, revisions in other items will logically flow from the revision of OASIS, such as changes to the HHA surveyors' pre-survey worksheets that focus on Outcome-based Quality Monitoring and Outcome-based Quality Improvement [OBQM & OBQI] reports, PPS guidance, changes in regulatory language, etc. 

As new OASIS-related information becomes available, DQA will add content/links on the new DQA OASIS Resource website, and/or highlight these in future editions of the DQA Quarterly Update.

New HH PPS Groupers/Versions

On September 20, 2009, CMS changed the format of the HH HIPPS Version code for OASIS assessments that have a M0090 completion date prior to 10/01/2009. The previous HIPPS Version code was 02.03 and has been changed to V2308. Home health agencies will receive warning message +257 on OASIS records submitted to the State OASIS System if their software has not been updated to reflect this change. Home health agencies should contact their software vendors if they are receiving this error.

In addition, CMS is updating the HH PPS Grouper due to changes in ICD-9-CM coding effective October 1, 2009. CMS is providing an updated HH PPS Grouper Software Package (Version V2409).

CMS also has available materials related to updating the HH PPS Grouper to reflect OASIS C implementation effective January 1, 2010. The materials provided include an updated version (V3110) of the grouper logic (JAVA source code). Information and materials related to HH PPS Grouper changes are available on the CMS HH PPS website at:

HAVEN 9.2 incorporates both the V2308 and the V2409 HIPPS Version Grouper changes and is available on the QIES Technical Support Office (QTSO) website at:

Questions regarding this information can be directed to:

Mary Jo Sutton, OASIS Education Coordinator


Chris Benesh, OASIS Automation Coordinator

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Home Health: New OBQM Training
Bureau of Technology, Licensing and Education / Technology Section

In August, a new Home Health training webcast was recorded to guide Home Health Agencies (HHAs) in utilizing their Outcome-Based Quality Monitoring (OBQM) reports. This webcast covers the basics for HHAs just beginning, or about to begin, their journey into the field of quality improvement. The presentation will provide a detailed discussion of the principals of an Outcome-Based Quality Management system, including important background information. It will also outline the steps that should be taken in the initial process of improving the quality of patient care within the HHA.

Since OBQM reports are individualized for each HHA and are derived from the OASIS data submitted through the state database, each report contains very valuable information about a HHA's results and compares their results to a national sample of HHAs. These reports have been available to HHAs since 2001, though HHAs may have delayed using them for lack of knowledge. This webcast attempts to educate HHAs on the uses and benefits of the reports and includes CMS's expectations surrounding the use of OBQM reports.

To view this 1.5 hour presentation on "OASIS and OBQM --- The Basics" visit: 

To download accompanying PowerPoint slides and handouts for use with the webcast, visit: 

Questions regarding this information, prior to or after viewing the webcast, can be directed to:

Mary Jo Sutton, OASIS Education Coordinator

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FDA MedWatch - GDH-PQQ Glucose Monitoring Technology: Possibility of Falsely Elevated 
Blood Glucose

Bureau of Health Services / Clinical Laboratory Section

The FDA has issued a notice for patients, hospital risk managers, and diabetes and other healthcare professionals of the possibility of falsely elevated blood glucose results when using GDH-PQQ glucose test strips on patients who are receiving therapeutic products containing certain non-glucose sugars. These sugars can falsely elevate glucose results, which may mask significant hypoglycemia or prompt excessive insulin administration, leading to serious injury or death.

GDH-PQQ glucose monitoring measures a patient's blood glucose value using methodology that cannot distinguish between glucose and other sugars. Certain non-glucose sugars, including maltose, xylose, and galactose, are found in certain drug and biologic formulations or can result from the metabolism of a drug or therapeutic product. The FDA Public Health Notification provides a list of GDH-PQQ Glucose Test Strips and recommends that healthcare practitioners avoid using GDH-PQQ glucose test strips in healthcare facilities or take steps to never use them on patients receiving interfering substances.

The FDA encourages the voluntary reporting of any medical device adverse events related to glucose meters or glucose test strips that do not meet the requirements for mandatory reporting. Adverse events should be reported to the FDA's MedWatch Adverse Event Reporting program by any of the following methods.

  • Online at
  • By phone at 1-800-332-1088
  • By completing and returning the postage-paid FDA Form 3500, located at:
    • by mail to MedWatch, 5600 Fishers Lane, Rockville, MD 20852-9787
    • by fax to 1-800-FDA-0178

Read the complete MedWatch 2009 Safety summary, including links to the Public Health Notification and Advice for Patients, at:

You are encouraged to report all serious adverse events and product quality problems to FDA MedWatch at:

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Guidance for Rapid Influenza Diagnostic Tests and Detection of
Novel Influenza A

Bureau of Health Services / Clinical Laboratory Section

DQA is alerting all members of the health care delivery system of the CDC's interim guidance for the detection of Novel Influenza A Virus using Rapid Influenza Diagnostic Tests. This interim guidance provides an overview of the sensitivities of rapid influenza diagnostic tests (RIDT) in detecting novel influenza A (H1N1) virus in order to help guide the reporting and interpretation of test results. The document can be found at:

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Measuring Hand Hygiene Performance
Bureau of Technology, Licensing and Education

DQA would like to direct health care professionals to the monograph, "Measuring Hand Hygiene Adherence: Overcoming the Challenge." This monograph is the result of the Consensus Measurement in Hand Hygiene (CMHH) project and a two-year collaboration involving The Joint Commission, The World Health Organization, World Alliance for Patient Safety, the Association for Professionals in Infection Control and Epidemiology, Inc., the Centers for Disease Control and Prevention, the Society for Healthcare Epidemiology of America, the Institute for Healthcare Improvement, and the National Foundation for Infectious Diseases.

The goal of this project was to identify promising and practical techniques for measuring adherence to hand hygiene guidelines, to provide a framework that would assist health care professionals when making necessary decisions regarding the measurement of hand hygiene performance, and to assure observable improvement in hand hygiene and national and international health.

The monograph is available on-line at:

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Department of Health Services TEXTNET (TTY) Directory
Bureau of Technology, Licensing and Education

DHS has a convenient directory of their several TEXTNET numbers at:

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Updated Medication Management Initiative Web Site
Bureau of Assisted Living

The Bureau of Assisted Living (BAL) recently updated all 16 pages of the Medication Management Initiative website to reflect changes in the new CBRF administrative rule, DHS 83, which became effective April 1, 2009.

If you have not already done so, we encourage you to visit the website and view the valuable information related to medication management at:

BAL continues to solicit new information, references, best practices, tools, and forms from any interested parties for inclusion on this website. Our intention is that this website be a "living document" to which new information is added on an on-going basis. If you have items for consideration, please forward them to the Assisted Living Regional Director in your region. Contact information for regional offices can be found at:

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DQA Numbered Memos (July, August, September 2009)

Listed below are DQA Numbered Memos distributed by DQA during the last quarter. You can access DQA Numbered memos at:

  • DHS Internet Site: 
  • Individual Provider Publication Pages:

    DQA Memos

    Memo No. Title Summary Providers Affected

    Feeding Assistant Training Program Updates

    This memo supplements DQA Memo 09-006 regarding the training of feeding assistants and contains important information on: Competency Evaluation Written Examination; Inactive Training Programs; Frequently Asked Questions; and Program Resources

    Feeding Assistant Training Programs
    Facilities for the 
    Developmentally Disabled
    Nursing Homes


    Wireless Handheld Device Useage

    This memo recommends uniform guidelines for the appropriate use of personal wireless handheld devices including, but not limited to, cell phones, cameras, and personal digital assistants (PDA's), as well as to raise awareness of the potential for misuse of such devices.

    Certified Mental Health and AODA
    Community-based Residential Facilities
    Facilities for the Developmentally Disabled
    Home Health Agencies
    Nursing Homes
    Licensed Adult Family Homes


    Statewide Waiver of Wisconsin Administrative Code Chapter DHS 83.59(2)(e)

    EFFECTIVE IMMEDIATELY,  the Bureau of Assisted Living is issuing a statewide waiver of DHS 83.59(2)(e), Wisconsin Administrative Code (until a revision to DHS 83 can be enacted), which states: "Toilet room doors shall not swing into a toilet room unless equipped with 2-way hardware."

    Community-based Residential Facilities


    F325 and F371 Question and Answer Document

    Two federal tags had significant changes in 2008. F326 was merged into F325 and F370 was merged into F371. The regulatory language remained the same for both tags. The revisions to tags F325 and F371 were made to provide clarification, explanation and examples for surveyors to reference. The Q&A document was developed in response to actual provider questions that were submitted to DQA. Answers were provided by the Division of Public Health, DQA, and the Centers for Medicare and Medicaid Services.

    Nursing Homes


    Notice of Change in Certification Fee for Residential Care Apartment Complexes

    This memo outlines a change in the fee structure for certified Residential Care Apartment Complexes (RCACs).

    Residential Care Apartment Complexes


    Notice of Change in Certification Fee for Adult Day Cares

    This memo outlines changes in the certification fee structure for Adult Day Cares (ADCs) consistent with the enactment of the state budget bill, Wisconsin Act 28, that became effective June 29, 2009.

    Adult Day Care Centers


    Notice of Change in Licensing Fee for Adult Family Homes

    This memo outlines changes in the licensing fee structure for Adult Family Homes (AFHs) consistent with the enactment of the state budget bill, Wisconsin Act 28, that became effective June 29, 2009.

    Adult Family Homes


    Notice of Change in Licensing Fee for Community-based Residential Facilities

    This memo outlines changes in the licensing fee structure for Community- based Residential Facilities (CBRFs) consistent with the enactment of the state budget bill, Wisconsin Act 28, that became effective June 29, 2009.

    Community-based Residential Facilities


    Physician Assistant Prescribing Rule Changes

    This memo informs DQA-regulated facilities of the "Physician Assistant Prescribing Rule Changes" in chapter Med 8 of the Wisconsin Administrative Code (Med 8), including answers to questions that may arise regarding the rule changes.

    Ambulatory Surgery Ctrs,
    Adult Day Care Centers
    Adult Family Homes
    Certified MH and AODA
    Community-based Residential Facilities
    End Stage Renal Dialysis Units
    Facilities for the 
    Developmentally Disabled
    Home Health Agencies
    Nursing Homes
    Outpatient Rehabilitation Facilities
    Residential Care Apartment Complexes
    Rural Health Clinics


DHS Administrative Rules Update
Administrator's Office

Access Department of Health Services (DHS) Administrative Rules 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 proposed rule was filed with the Clearinghouse and Legislative Reference Bureau on August 12, 2009. Public hearings on the proposed rule are scheduled for October 8 in Waukesha and October 14 in La Crosse. 

The Rule Order and Notice of Public Hearing for Chapter DHS 85, Private Non-profit Corporations and Unincorporated Associations as Guardians, has been posted on the Department's Administrative Rules website at the following link:

DHS 124 - Hospitals

During the early part of 2008 the Department of Health Services began working with hospitals, professional associations, advocates, and trade associations to revise Wisconsin Administrative Code, Chapter DHS 124. The Department is planning to update the code to eliminate overly prescriptive and outdated regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements.

While we are continuing to work on this extensive revision to the rule, new legislation makes it necessary for the Department to move forward with a limited number of revisions to ch. DHS 124 at this time. To that end, the Department amended the Statement of Scope for ch. DHS 124, dividing the revision of the rule into two separate processes.

The amended Statements of Scope were filed with the Legislative Reference Bureau on August 3, 2009. For more information, you may view the Statements 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 (July, August, September 2009)

Listed below are Survey and Certification (S&C) Letters distributed by CMS during the last quarter. All S&C memos can be viewed at the CMS internet site at:

S&C Memos
S&C No. Title Summary Providers Affected

ICFMR Clarification of Protection of Client's Rights

Regulations at 42 CFR 483.420(a)(4) state that clients in the ICFMR must be allowed to manage their financial affairs and be taught to do so to the extent of their capabilities. Determination of the appropriateness of a formal money management program is based upon the results of a comprehensive functional assessment and a consensus by the interdisciplinary team.

State Survey Agency Directors


Not Posted


Initial Surveys of CAH Distinct Part Units (DPUs) Changed to Tier 4 Priority Status

This memorandum amends the guidance contained in S&C-08-03, issued on November 5, 2007, concerning the workload priority for initial surveys of CAH DPUs. CAH DPU initial survey priority is changed from Tier 3 to Tier 4, effective 10/01/2009.

State Survey Agency Directors


Priority Order of Quality Indicator Survey (QIS) National Implementation in States

This memo provides States with a QIS implementation priority order for remaining States not currently implementing the QIS and offers guidance to support States' preparation for QIS implementation.

State Survey Agency


Clarification of Ambulatory Surgical Center (ASC) Interpretive Guidelines

This memo clarifies the ASC interpretive guidelines to indicate that an ASC and an Independent Diagnostic Testing Facility (IDTF) may not share space, even when temporally separated.

State Survey Agency


EMTALA Requirements and Options for Hospitals in a Disaster

This memo and attached fact sheet clarify options that are permissible under EMTALA and should reassure the provider community and public health officials that there is existing flexibility under EMTALA.

State Survey Agency


Surveying Facilities That Use Electronic Health Records (EHR)

The Department of Health and Human Services and CMS are committed to the goal that by 2014, most Americans will have access to health care providers who use EHRs. CMS recognizes the importance of the use of EHRs and their benefits to better patient/resident care and reduced costs.

State Survey Agency


Issuance of Revisions to Interpretive Guidance at F Tag 441, as Part of Appendix PP, SOM

This memo describes changes to surveyor guidance for Infection Control in Appendix PP of the SOM. The changes will provide clarification to nursing home surveyors when determining compliance with the regulatory requirements for infection control.

State Survey Agency


Flash Sterilization Clarification - FY 2010 Ambulatory Surgical Center (ASC) Surveys

State survey agencies using the new survey process in FY 2009, including completing the Infection Control Surveyor Worksheet, have experienced challenges in evaluating the use of flash sterilization by ASCs. This memo and Attachment 1 clarify what this term means and how to distinguish appropriate from inappropriate use of flash sterilization.

State Survey Agency


Frequently Asked Questions (FAQs) Related to the New ESRD Conditions for Coverage

In order to promote common understandings and consistency of standards and expectations regarding the new ESRD CfCs, CMS is distributing a series of FAQs that are related to those CfCs. The first in this series of Q&As (Wave One) is attached to this memorandum

State Survey Agency


Obtaining Civil Rights Clearances for Initial Certifications and CHOWs

The purpose of this letter is to remind State survey agencies of their role in the Office for Civil Rights (OCR) clearance process.

State Survey Agency


Advance Copy - Hospice State Operations Manual (SOM) Sections 2080-2089

The attached advance copy of the hospice sections of Chapter Two of the SOM includes revised interpretive guidance related to the revised Hospice CoPs that were effective December 2, 2008

State Survey Agency


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


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Last Updated: January 07, 2014