DQA Quarterly
Information Update
October 2011
PDF Version of this month's Quarterly
Update (PDF, 422 KB)
NEW THIS ISSUE
REGULAR FEATURES
NEW THIS ISSUE
Mandatory Reporting of Restraint and Seclusion Deaths
by Hospitals: E-mail & Fax Changes
Bureau of Health Services
The e-mail address and fax number for the mandatory reporting of
restraint and seclusion deaths by hospitals has changed, effective
September 16, 2011. They are:
Fax: (443) 380-8952
E-mail: 05RESTRAINTRF@CMS.HHS.GOV
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Dining Practice Standards
Bureau of Technology, Licensing and Education
The Pioneer Network has released new Dining Practice Standards agreed
upon by twelve clinical standard-setting associations.
The new Dining Practices Standards were developed by a Food and Dining
Clinical Standards Task Force, comprised of symposium experts,
representatives from Centers for Medicare and Medicaid Services Division
of Nursing Homes, the US Food and Drug Administration, the Centers for
Disease Control and Prevention, as well as national standard setting
groups.
These nationally agreed-upon, new food and dining standards of practice
support individualized care and self-directed living versus traditional
diagnosis-focused treatment for people living in nursing homes. The
document includes the following new standards of practice:
- Individualized Nutrition Approaches/Diet Liberalization
- Individualized Diabetic/Calorie Controlled Diet
- Individualized Low Sodium Diet
- Individualized Cardiac Diet
- Individualized Altered Consistency Diet
- Individualized Tube Feeding
- Individualized Real Food First
- Individualized Honoring Choices
- Shifting Traditional Professional Control to Individualized Support
of Self Directed Living
- New Negative Outcome
The Dining Practices Standards document can be accessed at: http://www.pioneernetwork.net/Latest/Detail.aspx?id=294
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RAI/MDS Updates
Bureau of Technology, Licensing and Education
RAI Manual Updates Effective 10/01/2011
The LTC RAI Manual has been updated to reflect changes that were
outlined in the SNF PPS FY2012 Final Rule and became effective 10/01/2011.
The revised manual also includes additional clarifications for coding
areas of the MDS. Sections that have been updated include the Table of
Contents, Chapter 1, Chapter 2, Chapter 3 (Introduction, Sections C, I, K,
M, N, and O), Chapter 4, Chapter 6, and Appendices A, B, C, E, and H.
Following is a summary of some of the changes noted in the revision.
Changes to the other Chapters and Sections can be found in change tables
located at the RAI Manual link below.
CHAPTERS 2 AND 6
- There is a new Timetable for scheduled SNF PPS assessments which
features an altered ARD window for all assessments except the
five-day.
- The updated definition of Leave of Absence includes the following
three factors:
- Temporary home visit of at least one night … or
- Therapeutic leave of at least one night … or
- Hospital observation stays less than 24 hours where the hospital
does not admit the patient
- The manual updates include instructions related to changes
in assessment requirements outlined in the Fiscal Year 2012 SNF PPS
Final Rule. This includes the following:
- Change of Therapy (COT) OMRA
- End of Therapy (EOT) OMRA, and EOT-Resumption (EOT-R)
- Clarifications and examples regarding Combining
Assessments have been added to the revised manual.
CHAPTER 3
- Section I. New phrasing has been added regarding when not to code
for active diagnoses.
- K0300. Clarification has been added regarding when weight loss
related to diuretics can be captured as a 'physician-prescribed weight
loss.'
- Section M. The revised manual has added instructions and an enhanced
example to clarify M1200G (non-surgical dressings) and M1200D
(Nutrition or Hydration Intervention to manage skin problems).
- Section O. There are many changes to this section, including the
following:
- Definitions
- Instructions regarding documentation of therapy
- Revision to instructions regarding co-treatments for Part A and
Part B
- Guidance regarding therapy students
- Updates relative to the different modes of therapy (individual,
concurrent, and group)
- Therapy start date and an EOT-R
- Instructions regarding O0450 Resumption of Therapy
- Clarification regarding O0600/O0700 Physician Examinations and
Physician Orders
The revised RAI Manual is available in a zipped file under the
Downloads area of the CMS MDS 3.0 Training Material website located at: https://www.cms.gov/NursingHomeQualityInits/
45_NHQIMDS30TrainingMaterials.asp
Additional information and training materials are also available on the
CMS SNF/PPS FY 2012 RUG-IV Education and Training website located at: https://www.cms.gov/SNFPPS/03_RUGIVEdu12.asp
Questions should be addressed to:
Margaret (Peg) Katz, RAI Education Coordinator
715-836-6748
margaret.katz@dhs.wisconsin.gov
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MDS Final Validation Report Transition RUG Messages
Changes to Skilled Nursing Facility Prospective Payment System (SNF
PPS) and the allocation of group therapy minutes effective October 1,
2011, impacts RUG-IV calculations. On the Minimum Data Set (MDS)
facilities should report unallocated group therapy minutes provided. The
FY 2012 RUG-IV grouper program will divide the reported minutes by four
and provide the appropriate RUG-IV group based on the allocated group
therapy minutes.
To allow for a smooth transition for billing between FY 2011 and FY
2012, facilities will be given the appropriate FY 2012 RUG code in warning
message number 1059 on final validation reports associated with
assessments submitted after September 18, 2011, with an assessment
reference date (ARD) between August 22, 2011, and September 30, 2011.
A facility may submit a modification to a Medicare PPS assessment if
the record was submitted before the FY 2012 RUG warning was turned on and
the assessment will be used to bill Medicare days in October 2011,
requiring a FY 2012 RUG. The final validation report for the modification
will return warning message 1059 and the appropriate FY 2012 RUG code.
For assessments with an ARD on or after October 1, 2011, the
appropriate FY 2011 RUG group will be provided on the final validation
reports in warning message number 1060. This is because these assessments
could be used for billing Medicare days prior to October 1st.
The DQA RAI/MDS Information web page includes links to additional
information related to changes being implemented October 1, 2011. This web
page can be accessed at: http://www.dhs.wisconsin.gov/rl_DSL/NHs/MDS30.htm
If you have questions regarding messages on final validation reports,
please contact:
Chris Benesh, Wisconsin MDS Automation Coordinator
608-266-1718
Chris.Benesh@dhs.wisconsin.gov
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Doug Englebert Receives Distinguished Service Award
Bureau of Technology, Licensing and Education
The Pharmacy Society of Wisconsin (PSW) awarded their 2011
Distinguished Service Award to Doug Englebert, RPh, MBA, and DQA Pharmacy
Consultant. The Distinguished Service Award is presented annually to
recognize and honor a Wisconsin pharmacist who has made outstanding
sustained contributions to the profession of pharmacy and the state
professional society of pharmacists. Many colleagues nominated Doug as
"they have witnessed first-hand the dedication and commitment that
Doug has brought to the Department of Health Services, Division of Quality
Assurance and the advancement of pharmacy practice."
"As a member of several committees, Doug serves as a
representative of the DQA, providing accurate state and federal regulatory
information, but he also works to convey the impact of various initiatives
on health care providers, including pharmacists and the patients they
serve. He is also a strong advocate for people living in health care
facilities."
"Doug has served on the PSW Senior and Long Term Care Board for
many years. He unselfishly gives of his time to this group, whether it is
participating in the quarterly meetings, scheduling a conference call, or
speaking at the PSW Senior Care Conference each spring. He has served as
editor of PSW's Newsline, for members of the Senior and Long Term Care
Section. Doug has served as a valuable resource for countless PSW members,
health care providers, and organizations across the state."
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Nurse Aide Registry Renewals
Office of Caregiver Quality
Federal and state regulations require that, in order for a nurse aide
to renew certification, s/he must have performed at least eight (8) hours
of nursing or nursing-related services for pay under the supervision of an
RN or LPN in the past twenty-four (24) months. The Nurse Aide Registry
Renewal Form is used to report the nurse aide's employment history in
order to maintain eligibility to work in certain federally certified
facilities. Failure to report the most recent date of employment to the
Registry will affect employment eligibility.
If the nurse aide has provided nurse aide services for at least eight
(8) hours for pay during the twenty-four (24) months before their
registration expiration date, the employing facility is required to enter
the date the individual most recently worked as a nurse aide in a
nursing-related service. Paid work in the following direct patient care
settings under the supervision of an RN or LPN may be considered: clinics,
community-based residential facilities (CBRFs), emergency centers, home
health agencies, hospices, hospitals, intermediate care facilities for
persons with mental retardation (ICFs/MR), nursing homes, and county or
school nursing.
The current or most recent health care employer should enter the name,
type of health care facility, full address, and telephone number of the
facility and indicate whether the nurse aide is a direct employee or a
contracted pool aide. A representative of the health care facility must
sign his/her name and date the form, verifying that an RN or LPN is
supervising the nurse aide's nursing-related duties. Please note that, if
the individual is employed by a temporary or pool agency, a representative
of the health care facility --- not of the temporary or pool agency ---
must complete this section.
Registry renewal is not contingent upon in-service hours and a nurse
aide's failure to attend regularly scheduled in-services should not impact
having their renewal notices signed.
'Questions? Contact the DQA Office of Caregiver Quality at:
Telephone: (608) 261-8319
Fax: (608) 264-6340
E-mail: DHSCaregiverIntake@dhs.wisconsin.gov
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CBRF Training Implementation and Improved Compliance
Bureau of Assisted Living
On April 1, 2009, the revised community based residential facility (CBRF)
rule, DHS 83, introduced new training requirements for CBRF staff. Full
implementation of the new CBRF training requirements occurred on April 1,
2010. New training curricula and instructor qualifications were developed
by the Department, and the University of Wisconsin Oshkosh Center for
Career Development and Employability Training (CCDET).
CCDET developed a program to certify instructors and maintain a
database of instructors and caregivers. During the first year of the
program from April 1, 2010 to March 31, 2011, there were 1,351 instructors
approved by CCDET to teach First Aid and Choking, Fire Safety, Medication
Administration, and Standard Precautions. During this time period,
approved instructors taught 10,311 classes to 30,867 participants! The
Bureau of Assisted Living congratulates CCDET and the assisted living
industry on this remarkable accomplishment.
Prior to the new requirements, data shows that initial CBRF staff
training consistently ranked in the Bureau of Assisted Living's Top 10
Citations. Since the implementation of the new training requirements, data
shows that initial CBRF staff training is no longer ranked in the Top 10
Citations. This trend in improved compliance is a testament to the
initiative and hard work of the Department, CCDET, and the assisted living
industry.
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Improvements to CBRF Student Registry Fees and
Trainer Renewal Criteria
Bureau of Assisted Living
Effective June 13, 2011, the CBRF Employee Registry processing fee was
reduced from $25.00 to $15.00 per successful participant for all required
department-approved CBRF training classes. This is a significant savings
for providers and students.
Additionally, in response to trainer concerns, the Bureau of Assisted
Living has reconsidered and reduced the number of continuing education
hours required for instructor renewals that require continuing education.
For those approved Fire Safety and Standard Precautions trainers who are
required to complete continuing education hours, the continuing education
hours required has been reduced from twelve (12) hours every two years to
six (6) hours every two years. (For those approved Medication
Administration trainers who are required to complete continuing education
hours, the hours of continuing education required remains at 12 hours
every two years.)
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REGULAR FEATURES
Changes in DQA Staff
Bureau of Technology, Licensing and Education
Denise Torgeson
On 08/01/11, Denise Torgeson, RN, transferred from the Bureau of
Nursing Home Resident Care to the Bureau of Technology, Licensing and
Education. Denise started with DQA as a nursing home surveyor in 2003.
Prior to that, Denise worked as a nurse in various healthcare settings.
Denise has assumed the position of Regulatory Specialist and will be
responsible for state enforcement of LTC facilities. Her office will be
located at 1 W. Wilson Street, Room 950.
Administrator's Office
Shari Busse
Shari Busse, Director of the DQA Office of Caregiver Quality (OCQ), was
appointed the Deputy Administrator of the DQA effective September 25,
2011. In this capacity, Shari will take on all operational
responsibilities with the primary focus of improving efficiency in how DQA
carries out its responsibilities and obligations. Shari comes to the
Deputy Administrator position following six years as the Director of the
OCQ and 13 years of state service in DHS and the Department of Workforce
Development. As OCQ Director, she has been instrumental in expanding and
enhancing Wisconsin's nurse aide training programs, increasing the number
of certified nursing assistants working in Wisconsin Health Care
facilities, expanding background check requirements in Wisconsin and
nationally, and has been the recipient of national awards on abuse and
neglect prevention of vulnerable residents training.
Shari graduated Magna Cum Laude with a Bachelor of Science Degree in
Criminology and a minor in Sociology in 1991 from Saginaw Valley
University, Saginaw, Michigan.
Bureau of Assisted Living
Vicky Steffens
Vicky Steffens has accepted the Health Service Specialist position at
the Northeastern Regional Office and will begin October 10, 2011. Vicky is
a Certified Social Worker and will graduate in December 2011 with a
Master's Degree in Public Administration. Vicky has experience working in
the assisted living industry as a caregiver, director of a CBRF and, most
recently, as a Mental Health Consultant.
Emily Schaefer
We are pleased to announce the return of Emily Schaefer to the Southern
Regional Office. Emily works as a License and Permit Program Associate (LPPA)
and is responsible for the counties of Crawford, Dane, Grant, Green, Iowa,
Lafayette, Richland, Rock, and Sauk. Emily worked as a LPPA for two and
half years, left state service, and is now back.
Nora Mendoza
The Bureau of Assisted Living, Southeastern Region, is very sad to say
farewell to Nora Mendoza, Quality Assurance Program Specialist - Senior.
Nora served in this position for six years, and really acted as the
regional director's right hand in an extremely busy region, helping the
staff to stay organized with their workload, performing important quality
assurance functions, and as a member of the management team serving on
many workgroups and coordinating special projects. Her dedication and
great sense of humor will be missed around the office, but we are very
happy for her as she begins a new chapter in state service. Nora will be
the supervisor of the new investigation unit within the Office of
Caregiver Quality, beginning October 10.
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DQA Numbered Memo (July, August, September 2011)
Administrator's Office
Listed below are DQA Numbered Memos distributed during the
last quarter. You can view these memos on the internet at: http://www.dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm
|
Memo No. |
Title |
Summary |
Providers Affected |
| 11-019 |
Revision: Environmental Suicide Prevention |
DSL-BQA-01-032, Environmental Suicide Prevention,
dated July 18, 2001, is revised to replace outdated information and
provide new environmental safety recommendations. This memo
clarifies regulatory requirements concerning the provision of a safe
environment in psychiatric hospitals and psychiatric units of
general hospitals. |
Hospitals |
| 11-020 |
Heat Awareness |
The purpose of this memo is to share a recent press
release issued by the Wisconsin Department of Military Affairs,
Division of Emergency Management and information issued by the
Wisconsin Department of Health Services identifying the dangers
associated with extreme heat and humidity and ways to promote
safety. |
Adult Day Care, Adult Family Homes, Ambulatory Surgery
Centers, Certified Mental Health and AODA, CLIA, Community Based
Residential Facilities, End Stage Renal Dialysis Units, Facilities
for the Developmentally Disabled, Home Health Agencies, Hospices,
Hospitals, Nursing Homes, Outpatient Rehabilitation Facilities,
Personal Care Providers, Residential Care Apartment Complexes, Rural
Health Clinics |
| 11-021 |
CMS S&C Memo 11-30 Reporting Reasonable Suspicion
of a Crime in a Long-Term Care Facility (LTC): Section 1150 B of the
Social Security Act |
See CMS S&S Memo 11-030. |
Facilities for the Developmentally Disabled, Hospices,
Nursing Homes |
| 11-022 |
US Department of Labor to Allow Limited Participation
of Youths in Operation of Power-Driven Patient Lifts |
The purpose of this memo is to share Field Assistance
Bulletin No. 2011-3, which details the circumstances under which 16-
and 17-year-olds will be permitted to assist in the operation of
power-driven resident lifts. This memo obsoletes DQA Memo 10-029.
This memo contains important information and guidance on the
following topics: U.S. Department of Labor Interpretation, Impact on
Nurse Aide Training Programs. |
Licensed Adult Family Homes, Certified Mental Health
and AODA Programs, Community Based Residential Facilities,
Facilities for the Developmentally Disabled, Home Health Agencies,
Hospices, Hospitals
Nursing Homes, Nurse Aide Training Programs, Personal Care
Providers, Residential Care Apartment Complexes |
| 11-023 |
Establishing an End Stage Renal Dialysis Forum |
The purpose of this memo is to invite Wisconsin End
Stage Renal Dialysis (ESRD) facility management staff to participate
in Quarterly Forums with DQA staff to discuss emerging issues in the
facilities. |
End Stage Renal Dialysis Centers |
| 11-024 |
2011 Wisconsin Act 2 Health Care Services Review Use
of Health Care Reports |
The purpose of this memo is to provide information to
health care providers regarding the effects of 2011 Wisconsin Act 2
on DHS / DQA activities. |
Community Based Residential Facilities, Facilities for
the Developmentally Disabled, Hospices
Hospitals, Nursing Homes, Residential Care Apartment Complexes |
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CMS Survey & Certification Letters (July, August,
September 2011)
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 at: http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
|
S&C No. |
Title |
Summary |
Providers Affected |
| 11-31 |
Changes to the Minimum Data Set Version 3.0 (MDS 3.0)
Assessment Modification |
This memo describes changes that the CMS has made to
the MDS 3.0 assessment modification and formatting policies, as well
as changes to the Nursing Home Compare website as a result of MDS
3.0 implementation. |
Nursing Homes |
| 11-32 |
Telemedicine Services in Hospitals and Critical Access
Hospitals |
On May 5, 2011, the CMS published a final rule (76 FR
25550), effective July 5, 2011, governing the agreements under which
a hospital or CAH may provide telemedicine services to its patients. |
Hospitals, Critical Access Hospitals |
| 11-33 |
Clarification of Rural Eligibility Status for Hospital
Swing Beds, Critical Access Hospitals |
Guidance is provided on determining rural location for
CAHs, hospital swing beds, and RHCs for a facility seeking CAH
designation must be located outside a Metropolitan Statistical Area
(MSA) or be treated as rural, and a hospital seeking swing bed
status or a clinic seeking RHC certification must be located outside
an area delineated as "urbanized" by the US Bureau of the
Census. |
Hospitals, Critical Access Hospitals, Rural Health
Clinics |
| 11-34 |
The Use of Video Cameras in Common Areas in
Intermediate Care Facilities for the Mentally Retarded (ICF/MRs) |
To ensure that client's rights are protected, the use
of video cameras in the ICF/MR must be reviewed, approved, and
monitored by the Specially Constituted Committee of the facility as
constituted per 42 CFR 483.440(f)(3)(i-iii). |
ICF/MRs |
| 11-35 |
Mandate of Section 6121 of the Affordable Care Act for
Nurse Aide Training in Nursing Homes |
The law mandates the inclusion of training for nurse
aides working in nursing homes on abuse prevention and care of
persons with dementia. Interpretive Guidelines have been revised for
the In-service Training Tag F497. CMS is developing a regulation to
mandate these topics and training materials that nursing homes may
use to train staff. |
Nursing Homes |
| 11-36 |
Hospital Patients' Rights to Delegate Decisions to
Representatives |
On April 15, 2010 the President issued a memo to the
Secretary of HHS directing the initiation of rulemaking to ensure
that hospitals respect the right of patients to have and designate
visitors. This memo provides clarifications of existing regulations
and policy guidance concerning new regulations that fulfill the
expectations of the President's memorandum. |
Hospitals, Critical Access Hospitals |
| 11-37 |
Issuance of Revisions to Interpretive Guidance at F
Tag 322, as Part of Appendix PP, State Operations Manual (SOM) |
The CMS made changes to surveyor guidance for Feeding
Tubes in Appendix PP of the SOM to provide clarification to nursing
home surveyors when determining compliance with the regulatory
requirements for feeding tubes. |
Nursing Homes |
| 11-38 |
Compliance with Food Procurement Requirements for
Nursing Homes with Gardens |
The CMS and the FDA have received inquiries from
nursing homes and State survey agencies asking if Federal law
permits nursing homes to have produce gardens and to use the foods
harvested on the menu for any portion of the resident population. |
Nursing Homes |
| 11-39 |
Guidance for State Survey Agencies Responding to
Requests for Survey Documents |
This memo provides updated guidance for the handling
of subpoenas duces tecum and other written requests that seek
disclosure of records in the possession of the State Survey Agency
(SA) as a result of the SA's implementation of its Agreement with
the Secretary, HHS under section 1864 of the SSA (section 1864
Agreement). |
All |
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Publication Contact: Gina Bertolini
E-Mail: Gina.Bertolini@dhs.wisconsin.gov
Phone: (608) 266-6691
MAIL SUBSCRIPTION SERVICES
http://www.dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM
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