DQA Quarterly Information Update

February 2005

[PDF Version of this month's Quarterly Update (PDF, 145 KB) - blue text indicates links to other pages or Internet sites]

• BQA Receives National Award
• Fifth Annual Long Term Care Conference
• BQA Numbered Memos November 2004-January 2005
• Starting Up Assisted Living Facilities – BQA Responses on the Internet
• Federal Background Check Pilot
• Outpatient Rehabilitation Services Contracting for Use of Swimming Pool
• Documenting Plans of Correction on the CMS 2567 Form
• Collaborative Project Assists Special Care Units
• OASIS Items
  • Enhanced CD-ROM mailed to Home Health Agencies
  • New Version of AT&T Global Dialer Required
  • Reference Available for Comprehensive Assessment Requirements
  • Frequently Asked Questions and Answers (Q&As)
• Home Health Medicaid and Medicare Certification Information
• Home Health Agency (HHA) Conditions of Participation (CoPs) Application to Patients Receiving Chore Services Exclusively
• Adoption of the 2000 edition of the Life Safety Code (LSC)
• Latest CMS Survey & Certification Letters
• Upcoming Training and Conferences
• Minerva Patient Lift Recall
• Administrative Rules Update
• Wisconsin Hospital Ranks High in Magazine’s National Scores

BQA Receives National Award

The Bureau of Quality Assurance (BQA) received a national award from the Association of Health Facility Survey Agencies (AHFSA) at its annual conference, held October, 2004 in St. Petersburg, Florida. The Wisconsin regulatory agency received first place in the area of "Quality Improvement" as a Promising Practice for its new assisted living survey process affecting 2,300 facilities in the state.

This process was designed in collaboration with many stakeholders, including advocates, providers, provider associations and state and county agencies. Innovative concepts and successful strategies from other states were incorporated into the process. The goal was to improve the overall quality of care and quality of life for residents and tenants living in assisted living facilities.

Fifth Annual Long Term Care Conference

Mark your calendars for Wednesday, August 10, 2005! We’re very excited to announce that the annual BQA conference will be a joint provider/ BQA surveyor conference. Caregivers and management from assisted living facilities, nursing homes and intermediate care facilities for persons with mental retardation, along with BQA surveyors for these facilities, will benefit from this year’s conference focus: a shared vision of person-centered care and the move to changing the culture of care. This year’s conference will be held in Appleton, WI at the Radisson Paper Valley Conference Center. Check the BQA Quarterly Updates and the website at http://dhfs.wisconsin.gov/rl_dsl/Training/index.htm for further information about this conference and other training opportunities.

BQA Numbered Memos November 2004-January 2005

Check out the new search feature on the BQA Numbered Memos’ page that searches for documents only within the http://dhfs.wisconsin.gov/rl_DSL/ pages. This should make it easier to search for the text of BQA memos, BQA Quarterly Information Updates, provider guidelines and other material of interest to staff and management of BQA-regulated entities.

Access these memos via http://dhfs.wisconsin.gov/rl_DSL/Publications/ BQAnodMems.htm or from individual providers' publications pages via http://dhfs.wisconsin.gov/rl_DSL/.

We have made obsolete the following BQA memos:

• 99-064 and 00-071 were replaced by BQA memo 04-028.

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Starting Up Assisted Living Facilities – BQA Responses on the Internet

BQA has added to the Internet standard responses to inquiries about starting up adult day care, adult family homes, community based residential facilities (CBRFs) and residential care apartment complexes (RCACs). These responses provide important information about the application processes, requirements, fees, contacts, and more. Please review the Providers links for the different assisted living facility types listed on http://dhfs.wisconsin.gov/rl_DSL/.

Federal Background Check Pilot

Wisconsin has been selected as one of seven states to participate in a comprehensive background check pilot program for new workers in long-term care facilities. This pilot was conceived by the federal Centers for Medicare and Medicaid Services (CMS) as another means to combat abuse and neglect in these settings. The other participating states are Alaska, Idaho, Michigan, Nevada, New Mexico, and South Carolina.

The CMS Background Check Pilot Program requires Federal Bureau of Investigation (FBI) criminal background checks to prevent people with serious criminal convictions from working in health care facilities as direct care staff. Wisconsin will receive a total award of $2,358,260 ($1,500,000 for the Background Check Program and an additional $858,260 for an Abuse Prevention Training Program).

Wisconsin's participation in the federal background check pilot program will result in:

• Increased assurance that caregivers with direct access to residents don't have convictions in other states; and,
• The gathering of data to evaluate the effectiveness and impact of Wisconsin's Caregiver Law, as well as the effectiveness of conducting FBI fingerprint-based checks.

The Abuse Prevention Training Program component aims to decrease abuse, neglect and misappropriation in health care facilities by establishing a team approach to effective abuse prevention, offering training for caregivers, and providing strategies for managers to use in selecting and supporting staff.

The Office of Caregiver Quality will implement and monitor the three-year pilot in five counties: Dane, Douglas, Kenosha, La Crosse, and Shawano. More information regarding the pilot will be issued in the near future.

Outpatient Rehabilitation Services Contracting for Use of Swimming Pool

BQA has recently received inquiries regarding outpatient rehabilitation providers contracting with a local pool for therapy services. According to a CMS letter from Steven Pelovitz dated September 20, 2000, an outpatient therapy (OPT) provider may contract with a local pool to offer aquatic therapy. The following conditions apply:

• A qualified therapist must be present and providing treatment to the beneficiary;
• The pool must be closed to the public during the therapy times;
• The pool must meet any health and safety criteria established by the local health department;
• The OPT provider should have written policies governing the OPT services provided (including aquatic therapy); and
• Aquatic therapy should have a doctor's order and be indicated on the patient’s plan of care.

If aquatic therapy is provided under arrangement with the pool authority, the services are to be furnished in accordance with the terms of a written contract, to include the identity of the qualified professional providing the service.

Documenting Plans of Correction on the CMS 2567 Form

We have received clarification from CMS about the requirement to submit the plan of correction (POC) on the CMS-2567 form submitted to providers upon completion of a survey. This arose from a provider question asking if a state agency requires the provider to submit their POCs on the 2567.

According to Chapter 2 of the State Operations Manual (exit DFHS), Section 2728B requires that the plan of correction be transmitted on the CMS-2567 opposite the deficiencies. This applies to both long-term care providers (nursing homes and facilities serving persons with developmental disabilities) and non-long-term care providers (hospitals, home health, hospice, etc.).

Collaborative Project Assists Special Care Units

A two-year project to support Alzheimer’s special care units in Wisconsin nursing homes to improve behavior symptom management has been launched as a collaborative effort between the Wisconsin Department of Health and Family Services Bureau of Quality Assurance and Bureau of Aging and Disability Resources.

The vision for the Alzheimer’s Nursing Home Project is to improve quality of life for people with Alzheimer’s and related dementia in Wisconsin nursing homes through two strategies:

• Decreasing the use of medications to address behavioral issues; and
• Replacing this practice with the use of person-centered strategies and practices that proactively decrease the likelihood of negative behaviors and focus residents’ energy and attention on meaningful activities, routines and experiences.

Nursing homes that are selected for this project will receive an individualized assessment to help staff establish an action plan, followed by training and ongoing technical assistance. The initiative promises to support special care units in greatest need of help and is made possible through civil money penalty funding.

The Nursing Home Alzheimer’s Project is projected to last two years.

The project began in the fall of 2004 with the establishment of an advisory committee consisting of professionals from the industry who are currently engaged in quality improvement, person-centered dementia care activities, surveyors, dementia experts, and related professionals. The committee has been working to establish the assessment tool, best practice guidelines and criteria for project participation. Selection of the first special care units to participate began in January 2005.

For more information on the Alzheimer’s Nursing Home Project, please contact Cathy Kehoe, Alzheimer’s Service Developer for the Department of Health and Family Services at 608-267-2439 or kehoecb@dhfs.state.wi.us.

OASIS Items

BQA mailed an enhanced CD-ROM, version 2.0c of the Outcome and Assessment Information Set (OASIS) Web-Based Training (WBT), produced by CMS, to all HHAs in November 2004. The WBT is a comprehensive training tool designed to provide agency clinicians with detailed instructions on OASIS. The enhanced CD-ROM is an updated version of the WBT and has:

• Improved audio quality and animations;
• Advanced clinical scenarios;
• An OASIS game;
• A Staff Development Guide;
• An OASIS paper-based test instrument with answer key; and
• A guided-tour orientation.

HHAs should use the Internet site at www.oasistraining.org as the primary WBT because it is updated regularly. The CD version of the WBT can be a secondary source of information for clinicians who do not have high-speed Internet access.

HHAs are required to use the AT&T Global Dialer for submission of OASIS assessment records to the State OASIS System. Effective 12/31/2004, HHAs are required to update the AT&T Global Dialer to Version 5. Previous versions of the dialer will no longer be supported.

Version 5 of the AT&T Global Dialer and installation instructions may be downloaded from the State OASIS System Welcome page or from the QIES Technical Support Office (QTSO) website at www.qtso.com.

CMS created a reference table listing the comprehensive assessment requirements for Medicare-approved HHAs. This table puts the comprehensive assessment requirements in an easy-to-read format. With a glance at the table, you can determine if OASIS assessments apply, if a comprehensive assessment is required, and when a follow-up comprehensive assessment is due for various types of patients (Medicare/Medicaid skilled, Non-Medicare/Non-Medicaid skilled, personal care only, chore services only). You can download the table from Bulletins on the State OASIS System Welcome Page.

HHA personnel frequently have questions on completing OASIS assessments for patients who are seen in the Emergency Room (ER). Following is the text of some Q&As from CMS to help clinicians determine the type of OASIS assessment to complete and how to respond to OASIS M0830 (emergent care) when the patient receives services in the ER. The resources for these Q&As are listed after each answer. You can obtain a complete set of these resources on the State OASIS System Welcome Page, under Bulletins.

Answer: "The OASIS ‘discharge due to death’ is used when the patient dies while still under the care of the agency (i.e., before being treated in an emergency department or admitted to an inpatient facility). A patient who dies en route to the hospital is still considered to be under the care of the agency and the death would be considered a death at home. A patient who is admitted to an inpatient facility or the hospital's emergent care center, regardless of how long he/she has been in the facility, is considered to have died while under the care of that facility. In this situation, the agency would need to complete any agency-required discharge documents (e.g., a discharge summary) and a transfer assessment to close out the OASIS episode." (Resource: CMS Q&As, August 2004)

Answer: "Emergent care includes all unscheduled visits to medical services as noted in the response options, including a hospital emergency room. You should mark M0830 with response 1 -Hospital emergency room. In this situation, since the patient was admitted to the hospital following the emergency room visit, you would also complete the items for Transfer to the inpatient facility. (RFA 6 or 7 to M0100)." (Resource: CMS Q&As, August 2004)

Answer: "If the patient was never admitted to the inpatient facility, this encounter would be considered emergent care. The time period that a patient can be ‘held’ without admission can vary from location to location, so the clinician will want to verify that the patient was never actually admitted to the hospital." (Resource: CMS Q&As, August 2004)

Answer: "If the patient is pronounced ‘dead on arrival,’ then the patient is presumed to have passed away while under the care of the agency, and would be considered a death at home. If the patient is not pronounced ‘dead on arrival,’ is taken under care by the emergency department, and subsequently dies, the patient is considered to have died while under the care of the emergency facility, and not under the care of the home health agency, and would not be considered a ‘death at home’." (Resource: 10/20/04 CMS letter to OCCB)

Answer: "The item-by-item response-specific instructions in Chapter 8 of the Implementation Manual clarify that response to M0830 – Emergent Care, include the entire period since the last time OASIS data was collected, including current events. Any access of emergent care, regardless of how brief the encounter, should be reported on M0830 if it occurred since the last time OASIS data was collected." (Resource: 10/20/04 CMS letter to OCCB)

Home Health Medicaid and Medicare Certification Information

In our continuing efforts to streamline our processes, we have posted all the necessary links for information on the process for certifying Wisconsin home health agencies to accept Medicare and Medicaid recipients. Formerly, these materials would be mailed to home health agencies that had completed their Wisconsin licensure and were ready to be certified. We will now refer agencies to this site instead: http://dhfs.wisconsin.gov/rl_DSL/HHAs/HHAmedcerts.htm.

This site contains the following:

• Code of Federal Regulations and State Operations Manual links;
• Outcome and Assessment Information Set (OASIS) links, plus appropriate database download link instructions; and

• Required federal forms, including those for the federal Civil Rights Office.

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Home Health Agency (HHA) Conditions of Participation (CoPs) Application to Patients Receiving Chore Services Exclusively

CMS has issued a Survey & Certification letter 05-06 regarding its policy for the application of the HHA CoPs to patients receiving chore services exclusively. The letter:

• Provides guidance to surveyors on the application of the Medicare CoPs to those patients receiving only chore (or certain other non-medical) services from the HHA;
• Provides that a HHA is not required to conduct a comprehensive assessment on individuals where HHA services are entirely limited to housekeeping, chore, or certain other non-medical services; and
• Reinforces the mandate that as soon as the HHA provides any Medicare service to these individuals, or any standard service permitted by Federal law under the Medicaid State Plan, CMS will consider the individuals to be receiving medical care and the CoPs will apply.

Wisconsin Administrative Code HFS 133 for HHAs does not preclude the implementation of this policy. HHAs must be aware that certain payer sources may have requirements that differ from this policy and therefore would supercede the policy for payment purposes.

Survey & Certification letter 05-06 is posted at www.cms.hhs.gov/ medicaid/survey-cert/sc0506.pdf. Please feel free to contact Marianne Missfeldt at missfml@dhfs.state.wi.us if you have additional questions.

Adoption of the 2000 edition of the Life Safety Code (LSC)

The Department of Health and Family Services has incorporated the 2000 edition of the Life Safety Code (LSC) into the Wisconsin Administrative Rules for hospitals, hospices, nursing homes, and facilities serving people with developmental disabilities. This incorporation aligns the department with the parallel federal requirement to use the 2000 edition, aiding efficient physical plant enforcement. The LSC language has been placed in the following rules effective December 2004:

• Hospitals - HFS 124: www.legis.state.wi.us/rsb/code/hfs/hfs124.pdf and Appendix A www.legis.state.wi.us/rsb/code/hfs/hfs124_app_a.pdf

• Hospices - HFS 131 at www.legis.state.wi.us/rsb/code/hfs/hfs131.pdf

• Nursing Homes - HFS 132 at www.legis.state.wi.us/rsb/code/hfs/hfs132.pdf and Appendix A at www.legis.state.wi.us/rsb/code/hfs/hfs132_app_a.pdf

• Facilities Serving People with Developmental Disabilities - HFS 134 at www.legis.state.wi.us/rsb/code/hfs/hfs134.pdf and Appendix A at www.legis.state.wi.us/rsb/code/hfs/hfs134_app_a.pdf

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Latest CMS Survey & Certification Letters

Below is a list of Survey and Certification (S&C) Letters distributed by CMS during the last quarter. Letters pertaining only to state agency operations are omitted. All S&C Letters can be viewed as PDF files at the Internet site www.cms.gov/medicaid/survey-cert/letters.asp [link not operable at this time]. If you have questions about individual letters, contact Susan Hespen of BQA at (608) 266-0582, or e-mail hespesj@dhfs.state.wi.us.

Upcoming Training and Conferences

Check our online training site at http://dhfs.wisconsin.gov/rl_DSL/Training/index.htm.

Minerva Patient Lift Recall

The federal Food and Drug Administration and Arjo, Inc., notified healthcare professionals of a Class I recall of the Minerva Patient Lift (models ML-20 and ML-30), a battery-operated lift designed for lifting and transporting patients. There are three mechanical problems prompting the Minerva patient lift recall:

• A missing spring washer on the hanger bar, causing it to detach from the lift, resulting in the patient falling to the ground;
• A bolt in the foot pedal assembly becoming loose, allowing the assembly to fall off the lift. The lift can become unstable and cause the patient to fall; and
• Some units may have faulty actuator brackets on the mast assembly that can also cause the lift to become unstable.

Read the MedWatch 2004 safety summary, including links to the FDA recall notice, at www.fda.gov/medwatch/SAFETY/2004/safety04.htm#medibo.

Administrative Rules Update

The HFS 83 re-write committee continues to work with an advisory committee consisting of various providers and association representatives to develop the proposed rules for the Administrative Rule Chapter HFS 83. A final draft is anticipated by March 2005. Upon approval from the Secretary's Office, the proposed rules will be sent to the Legislative Council Rules Clearinghouse in July 2005. See the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov for more information.

The rule revisions in the "Long Term Care Rulemaking Order" are now published in copies of the administrative rules HFS 132 and HFS 134 dated October 2004. These rules became effective November 1, 2004. Providers can find copies of the rules on the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov.

A copy of the full text of the rule, the full text of the fiscal estimate, and other documents associated with this rulemaking order are also available on this website. You can also register to

receive e-mail notification whenever the Department posts new information about rules. During the public comment period, you can submit comments on rulemaking orders and view comments that others have submitted about the rules.

On October 15, 2004, the Wisconsin Administrative Register published the "Statement of Scope" relating to the department’s proposal to revise HFS 133. Providers can view the proposed revisions on the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov.

HFS 148 – "Cancer Drug Repository Program"

BQA worked with an advisory committee consisting of internal and external stakeholders to develop the proposed rules for the Administrative Rule Chapter HFS 148, the "Cancer Drug Repository Program." 2003 Wisconsin Act 175 created s. 255.056, Stats, which requires the Department to establish and maintain a cancer drug repository program and promulgate administrative rules for the program. BQA expects to send the proposed rules to the Legislative Council Rules Clearinghouse in early 2005. The proposed rules are subject of a Statement of Scope published on June 30 in the Wisconsin Administrative Register. A copy of the Statement of Scope of proposed rules for HFS 148 is available on the Administrative Rules website at http://adminrules.wisconsin.gov.

The rule revisions in the 2003 "Omnibus Rulemaking Order" are now published in the November 2004 copy of the administrative rules for the following BQA health-facility related rules: HFS 13, HFS 124 and HFS 131. These rules became effective on December 1, 2004. Copies of these rules are on the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov.

A copy of the full text of the rule, the full text of the fiscal estimate and other documents associated with this rulemaking order are also available on this website.

For questions about BQA-related rules, contact Cheryl Bell-Marek at (608) 264-9896 or e-mail at bellmcj@dhfs.state.wi.us [replaced by Pat Benesh].

Wisconsin Hospital Ranks High in Magazine’s National Scores

The following information was taken from a flier put out by Children’s Hospital of Wisconsin, Milwaukee:

Child magazine has rated Children’s Hospital of Wisconsin as the third best children’s hospital in the nation. In subspecialties, Children’s Hospital’s Emergency Department earned the elite ranking of number one in the nation in pediatric emergency medical care, and the Herma Heart Center was rated fifth in pediatric cardiac care. Survey results and articles about the top ten children’s hospitals and five "super-specialties" are published in the February 2005 issue of Child magazine.

"This is only the third time that Child magazine has published this biennial report, and was by far the closest race to date," said Karen Cicero, senior editor of Child magazine. "Children’s Hospital of Wisconsin clearly emerged as a leader not only in the top ten, but as the prestigious third in the nation. The quality of pediatric care the hospital provides on so many levels is most impressive."

In order to be selected, hospitals had to be a full voting member of the National Association of Children’s Hospitals and Related Institutions (NACHRI). From the group of 144 qualified members, the field was narrowed to nearly 100 institutions, based on evaluations by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The semifinalists received the 164-question survey developed by Child magazine’s medical advisory board in spring, 2004. The survey addressed critical areas of pediatric-specific care surrounding survival rates, heart surgeries, solid organ transplants, neonatology, staff qualifications, nurse-to-patient ratios, research and clinical trials, family support and other services unique to pediatric health care.

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