DQA Quarterly
Information Update
July 2012
PDF Version of this month's Quarterly Update (PDF,
136 KB)
NEW THIS ISSUE
REGULAR FEATURES
NEW THIS ISSUE
FOCUS 2012
Bureau of Education Services an Technology
FOCUS 2012: Special Session
November 28, 2012
"The Art and Science of Fall Prevention"
FOCUS 2012: Conference
November 29, 2012
"Mission Possible!"
The Wisconsin Department of Health Services (DHS), Division of Quality
Assurance (DQA), is pleased to announce the 11th annual conference for
health care providers and DQA staff on November 28 and 29, 2012 at the
Kalahari Convention Center in Wisconsin Dells. The Focus 2012 Conference
is being developed in collaboration with health care provider and provider
association representatives.
At FOCUS 2012, attendees will have access to leading experts in the
health care field, the chance to network with others, and an opportunity
to visit the numerous exhibit booths.
This year, the Special Session will focus on Fall Prevention. This
topic is receiving special attention in order to increase both awareness
of the issue and efforts to reduce the high incidence of falls in
Wisconsin. This special session is intended for staff from assisted living
facilities, facilities serving people with intellectual disabilities, home
health agencies, hospice providers, hospitals, and nursing homes, as well
as occupational therapy and physical therapy professionals, pharmacists,
medical directors of nursing homes, and the Division of Quality Assurance.
The Special Session keynote speaker will feature Aleksandra Zecevic,
PhD, Assistant Professor at Western University, London, Ontario. Her
presentation is titled, "Understanding Falls and Falls
Prevention". This presentation will provide an overview and scope of
the problem, falls in diverse health care settings, injuries, cost, and
prevention. Dr. Zecevic will also present a plenary session titled,
"The CSI of a Fall --- A Systems Approach to Investigating Causes of
Falls". This session will cover systems issues vs. person centered
approaches, why falls assessments are not enough, safety culture, and how
falls can help improve health care safety.
Several breakout sessions will be offered covering topics which include
risk management, the effects of medications on falls, and equipment
considerations.
The theme of the FOCUS 2012 Conference is, "Mission
Possible!" The goal of the conference is to provide attendees with as
many tools as possible to improve the health and safety of Wisconsin
residents living in health care facilities. This conference is intended
for staff from assisted living facilities, facilities serving people with
intellectual disabilities, nursing homes, and the Division of Quality
Assurance.
The keynote speaker is Dr. David Gifford, MPH, American Health Care
Association and National Center for Assisted Living Senior Vice President
of Quality and Regulatory Affairs. The title of his presentation is
"Quality Improvement: Role of Healthcare Leadership and Regulations
to Achieving High Quality Outcomes." Dr. Gifford will discuss the
roles leaders play in guiding their clinical staff to achieve quality care
and comply with health care regulations, using real case scenarios from
different health care settings related to patient safety.
The agenda for this innovative conference includes 42 breakout sessions
on topics which include hydration status, culturally diverse needs,
infection control, nurse delegation, dining standards, delirium, oral
care, and many other topics.
The UW Stevens Point, Education-Conference Planning Office will begin
registration the first week in September. The conference/registration
website is:
http://www.uwsp.edu/conted/ConfWrkShp/Pages/Focus2012.aspx
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Hospice Interface Agreements with Nursing Homes,
CBRFs, and RCACs
Bureau of Health Services
The Bureau of Health Services recently posted updated care
coordination guidelines for assisting providers in their development of
contracts for the provision of services for residents, patients, and
tenants who elect their hospice benefit. Three specific guidelines are
developed and reflect current regulatory requirements specific to the
relationships between hospice, nursing homes, CBRFs, and RCACs. These new
guidelines can be found at:
Nursing Home: http://www.dhs.wisconsin.gov/publications/p0/p00252.pdf
CBRF: http://www.dhs.wisconsin.gov/publications/p0/p00314.pdf
RCAC: http://www.dhs.wisconsin.gov/publications/p0/p00315.pdf
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The Updated "Bad Bug Book"
Bureau of Education Services an Technology
The U.S. Food and Drug Administration has updated the "Bad Bug
Book," a handbook of basic information about foodborne bacteria,
viruses, parasites, prions, and naturally occurring toxins.
The updated edition of the "Bad Bug Book" is available on the
FDA web site at:
http://www.fda.gov/downloads/Food/FoodSafety/FoodborneIllness/
FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/UCM297627.pdf
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PASARR vs. MDS Change of Status Requirements
Bureau of Nursing Home Resident Care
The Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI)
Manual may be downloaded from the Centers for Medicare and Medicaid
Services (CMS) at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/MDS30RAIManual.html
Within Chapter 2, Assessments for The Resident Assessment Instrument (RAI),
pages 2-20 through 2-27 deal with "significant change in status
assessment (SCSA)." The last two of these pages refers to the
interface between the "significant change in status" related to
the MDS and the Preadmission Screening and Resident Review (PASARR)
process. The following bullets are significant:
- PASARR is not a requirement of the resident assessment process, but
is an OBRA provision that is required to be coordinated with the
resident assessment process. This guideline is intended to help
facilities coordinate PASARR with the SCSA; the guideline does not
require any actions to be taken in completing the SCSA itself.
- Facilities should look to their state PASARR program requirements
for specific procedures.
Wisconsin's PASARR policies are detailed in the "PASARR
Requirements" which are in an attachment to the numbered memo, DDES
No. 2004-16, which can be accessed at:
http://www.dhs.wisconsin.gov/dsl_info/NumberedMemos/DDES/CY_2004/2004-16-PASARRreq.pdf
The requirements for a PASARR "change of status review" are
provided on page two of this attachment - note that the PASARR requirement
are not the same as the MDS requirements:
Beginning January 1, 1997, Wisconsin Medicaid-certified nursing
facilities no longer need to have an annual resident review for any
resident. Until the federal Health Care Financing Administration
promulgates new regulations implementing this change in the federal law as
relayed in a future informational memorandum, Medicaid-certified nursing
facilities must make a referral for a "change in status" review
under the following situations:
- A client who is admitted under a permissible short-term exemption
(e.g., for a post-hospitalization recuperative care stay for up to
30 days) and needs to stay longer beyond the timeframe for the
permissible exemption must be referred for a Level II Screen on or
before the last day of the permitted timeframe if any of the
questions in Section A of the PASARR Level I Screen are checked
"yes";
- A client whose medical/physical condition improves to a level to
cause the nursing facility to suspect that the client's needs could
be met in an appropriate community setting, as described in the
PASARR regulations and preamble, must have a resident review;
- A client who previously received a PASARR review and was found to
need specialized services must receive a resident review if his/her
level of independent functioning improves such that he/she no longer
requires continuous and aggressive treatments and services to
address limitations in independent functioning caused by the
client's mental illness or developmental disability;
- A client whose independent functioning now is significantly
limited as a result of a mental illness or developmental disability,
but previously was not significantly limited must receive a resident
review;
- If the responses to all questions 1 - 5 in Section A of the Level
I screen for a client at the time of his/her admission to a nursing
facility are checked "no" but the response to one or more
of these questions should have been "yes"; or
- A client who previously received a PASARR review and was found to
need specialized services must receive a resident review if his/her
level of independent functioning declines due to a marked and
permanent deterioration in his/her cognitive functioning due to
dementia or health status such that he/she is unable to participate
or benefit from specialized services. Note: The state and federal
nursing home regulations require that the facility update the
client's MDS and care plan to reflect the change in condition.
Nothing in the nursing facility regulations implies that the
facility should wait for the results of a new Level II screen before
updating the client's care plan.
For additional information, contact:
Dan Zimmerman
PASARR Contract Administrator
Bureau of Prevention, Treatment and Recovery
1 W. Wilson Street, Room 851
Madison, WI 53703
608-266-7072
608-267-7793 (fax)
Daniel.Zimmerman@dhs.wisconsin.gov
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Accreditation of Rural Health Clinics
Bureau of Education Services an Technology
In March 2012, the Centers for Medicare and Medicaid (CMS) deemed the
American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
(Quad A) to accredit Rural Health Clinics. This accreditation process is
available for both new and current Rural Health Clinics. Any facility
accredited by the AAAASF Quad A will be automatically deemed to meet the
Rural Health Clinic survey and certification standards for Medicare.
The CMS announcement and memo can be found at:
Announcement: http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/pdf/2012-6331.pdf
Memo: http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-12-33.pdf
More information about certification, including applications and
standards, can be accessed at:
http://www.rhcaccreditation.org/
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REGULAR FEATURES
Changes in DQA Staff
Bureau of Education Services and Technology (BEST)
The Bureau of Licensing, Education and Technology (BTLE)
is now the Bureau of Education Services and Technology (BEST). A recent
restructuring effort moved the licensing staff for nursing homes,
hospitals, home health, and hospice to their respective bureaus. In light
of that change, BTLE has become BEST and will continue its focus on
providing educational services and technology assistance to both DQA staff
and providers. Alfred Johnson, BEST Director, has been appointed Interim
Director of the Bureau of Assisted Living (See below for more
information.); therefore, Shari Busse, Deputy Administrator, is serving as
the Interim BEST Director. If you have any questions, please contact Shari
at: shari.busse@dhs.wisconsin.gov
Kevin Coughlin - Resignation
Kevin Coughlin resigned his position with the Division of Quality
Assurance and started a new assignment within the Division of Long-term
Care (DLTC) starting May 7, 2012. Kevin will remain involved with DQA in a
couple of areas, most notably the WCCEAL program, the collaboration with
UW-Madison Center for Health Systems Research and Analysis (CHSRA). DQA is
disappointed to see Kevin go, but the excellent work he has started will
continue under new leadership. Best wishes, Kevin!
Alfred Johnson - Reassignment
Bureau of Assisted Living
Alfred Johnson, Director of the Bureau of Education Services and
Technology (formerly BTLE), has been appointed Interim Director of the
Bureau of Assisted Living effective Monday, June 4, 2012. Alfred has
served in his current capacity since 2008. Prior to becoming the Director
of BTLE, Alfred served as Assisted Living Regional Director in Milwaukee
and prior to that in the same position in Green Bay (now DePere) office.
Having someone in this role who is familiar with the industry allows the
continuation of the fantastic work and collaboration that has taken place
within the Bureau.
Paul Peshek - Reinstatement
Bureau of Nursing Home Resident Care / Northeastern Regional Office
Paul Peshek has returned to BNHRC as the RFOD in the De Pere Regional
Office. Paul began his duties on March 26, 2012. Prior to his departure
from DQA last year, Paul was the Director of the Bureau of Nursing Home
Resident Care, and also served as the Regional Field Operations Director
in De Pere.
Kathy Lyons - Reassignment
Bureau of Assisted Living / Northeastern Regional Office
Kathy Lyons is the new Assisted Living Regional Director for the NERO.
Kathy was reassigned from her old position as the Regional Field Operation
Director (RFOD) with the Bureau of Nursing Home Resident Care (BNHRC) to
her new position in BAL effective May 6, 2012. Kathy comes to us with a
wealth of knowledge, education, and experience in regulation and provision
of services in long term care. Kathy began her career with DQA in 2003
when she joined BNHRC as a regional field operation supervisor in WRO
until she was promoted to the RFOD position in 2009. Prior to her career
with DQA, Kathy managed a full service medical equipment company, served
as an administrator of a 100-bed nursing home, and as the Quality Assurance
Director for another nursing home. Kathy holds a Bachelor of Science
degree from both University of Wisconsin-Eau Claire and University of
Wisconsin-Stout. She is also licensed as a Wisconsin Nursing Home
Administrator.
Lynnette Traas - Reassignment
Bureau of Health Services
Lynnette Traas has accepted the Section Chief's position for the new
Licensing, Certification and CLIA Section (LCCS) in the Bureau of Health
Services. Lynnette is currently the Quality Assurance Program
Specialist-Senior in the Bureau of Assisted Living (BAL). Lynnette comes
to BHS with experience as a surveyor, prior supervisory experience, policy
development, a wealth of knowledge regarding enforcement, and is
experienced in interpreting regulations. Lynnette played a pivotal role in
the development of best practices submitted to AHFSA; the BAL were awarded
for submissions. Lynnette has a Bachelor of Science degree in Social Work
and a Master of Science in Clinical Psychology.
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DQA Numbered Memos (April, May, June)
Access these memos via
http://www.dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm
or via individual providers' publications pages at
http://www.dhs.wisconsin.gov/rl_DSL/
|
Memo No. |
Title |
Summary |
Providers |
| 12-03 |
Independent Informal
Dispute Resolution (Independent IDR) |
This memorandum describes
the procedure under which federally certified nursing homes may
dispute certain deficiencies using the Independent IDR process. |
Federally Certified Nursing
Homes |
| 12-04 |
Changes in the Division of
Quality Assurance Bureau of Assisted Living - Southern Regional
Office |
This memo informs providers
of a change in location for the Division of Quality Assurance,
Bureau of Assisted Living (BAL), Southern Regional Office. |
Adult Day Care
Adult Family Home
Community-based Residential Centers
Residential Care Apartment Complexes |
| 12-05 |
Guidance for the Safe Use
of Oxygen - Use of Hair Dryers |
This memorandum provides
guidance regarding the safe use of oxygen in residential and
health care facilities and was prompted by recent observations of
residents using oxygen in facility beauty salons. |
Adult Family Homes
Community-based Residential Facilities
Facilities Serving People with Developmental Disabilities
Nursing Homes
Residential Care Apartment Complexes |
| 12-06 |
2011 Wisconsin Act 161
Authorizing Physician Assistants to Complete Certain
Medically-Related Actions in Nursing Homes and Community Based
Residential Facilities |
The purpose of this memo is
to provide information to health care providers regarding the new
law. |
Community-based Residential
Facilities
Facilities Serving People with Developmental Disabilities
Nursing Homes |
| 12-07 |
Medication Setup in
Assisted Living and Adult Day Care |
This memo addresses who may
set up medications for residents/tenants/participants to take or
for unlicensed assisted living staff or adult day care staff to
administer. |
Adult Day Care Centers
Adult Family Homes
Community-based Residential Facilities
Residential Care Apartment Complexes |
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CMS Survey & Certification Letters (April, May,
June)
Listed below are Survey and Certification (S&C)
Letters distributed by the Centers for Medicare & Medicaid Services
(CMS) during the last quarter. Please note that the CMS Internet site for
reviewing all S&C memos is:
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html
| S&C No. |
Title |
Summary |
Providers Affected |
|
12-29 |
Promising Practices for Implementing
the Medicare Hospice Benefit for Nursing Home (NH) Resident |
The memo informs that CMS has developed
several promising practices for the successful implementation of
the Medicare Hospice Benefit for nursing home residents |
Nursing Homes |
|
12-30 |
Use of Insulin Pens in Health Care
Facilities |
Reports to CMS indicate that some
healthcare personnel do not adhere to safe practices and may be
unaware of the risks these unsafe practices pose to patients.
Insulin pens are meant for use by a single patient only. Sharing
of insulin pens must be cited, consistent with the applicable
provider/supplier specific survey guidance, in the same manner as
re-use of needles or syringes. |
All |
|
12-31 |
Environmental Scan of State Survey
Agency Training Coordinators and Healthcare Associated Infections
(HAI) Coordinators Nursing Home HAI Prevention programs |
Notification: CMS will conduct a
Healthcare Associated Infections (HAI) Prevention Program
Environmental Scan of State Survey Agency Training Coordinators
and State HAI Coordinators.
State Selection: All states except those already contacted
during pilot.
Effective Date: The environmental scan will begin in May 2012. |
Nursing Homes |
|
12-32 |
Patient Safety Initiative Pilot Phase -
Revised Draft Surveyor Worksheets |
Patient Safety Initiative: CMS is
testing three revised surveyor worksheets for assessing compliance
with three hospital CoPs --- QAPI, Infection Control, and
Discharge Planning --- as a means to reduce hospital-acquired
conditions, including healthcare associated infections, and
preventable readmissions.
Via this memo, CMS is making these revised draft worksheets
publicly available and emphasizes that there may be additional
revisions based on information gathered during the pilot test
phase. |
Hospitals |
| 12-33 |
Approval of the American Association
for Accreditation of Ambulatory Surgery Facilities' (AAAASFs')
Rural Health Clinic (RHC) Accreditation Program |
CMS has recognized AAAASF as a national
AO with an approved accreditation program for RHCs seeking to
participate in the Medicare or Medicaid programs. This approval
provides RHCs with an accreditation option which previously did
not exist. |
Rural Health Clinics
Accreditation Organization (AO) Deeming Approval. |
| 12-34 |
Clarification and revisions to
Interpretive Guidance at F Tag 492, as Part of Appendix PP, State
Operations Manual (SOM) for Long Term Care (LTC) Facilities |
This memorandum clarifies and revises
the CMS guidance to Surveyors in Appendix PP of the SOM regarding
citations under Tag F492. |
Nursing Homes |
| 12-35 |
Safe Use of Single Dose/Single Use
Medications to Prevent Healthcare-associated Infections |
Under certain conditions, it is
permissible to repackage single-dose vials or single use vials
into smaller doses, each intended for a single patient: The United
States Pharmacopeia (USP) has established standards for
compounding which, to the extent such practices are also subject
to regulation by the Food and Drug Administration (FDA), may also
be recognized and enforced under §§501 and 502 of the Federal
Food, Drug and Cosmetics Act (FDCA). |
All |
| 12-36 |
Revised Hospital Conditions of
Participation (CoPs) - Governing |
Revised Hospital Regulations Effective
July 16, 2012: CMS has adopted a number of changes to the hospital
CoPs and is in the process of developing interpretive guidelines
to assist surveyors in assessing compliance under the revised
regulations. |
Hospital |
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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
Last Revised:
March 21, 2013
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