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DQA Quarterly
Information Update

October 2011

PDF Version of this month's Quarterly Update (PDF, 422 KB)




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

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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:

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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.


  1. There is a new Timetable for scheduled SNF PPS assessments which features an altered ARD window for all assessments except the five-day.

  2. 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
  1. 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)
  1. Clarifications and examples regarding Combining Assessments have been added to the revised manual.


  1. Section I. New phrasing has been added regarding when not to code for active diagnoses.

  2. K0300. Clarification has been added regarding when weight loss related to diuretics can be captured as a 'physician-prescribed weight loss.'

  3. 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).

  4. 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:

Additional information and training materials are also available on the CMS SNF/PPS FY 2012 RUG-IV Education and Training website located at:

Questions should be addressed to:
Margaret (Peg) Katz, RAI Education Coordinator

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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:

If you have questions regarding messages on final validation reports, please contact:

Chris Benesh, Wisconsin MDS Automation Coordinator

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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

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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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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:

Memo No.



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:

S&C No.



 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
Phone:  (608) 266-6691


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