DQA
Quarterly Information Update
November 2005
[PDF
Version of this month's Quarterly Update (PDF,
103 KB) - blue text indicates links to other pages or
Internet sites]
Last Hard Copy Issue!
This will be the last hard copy of the OQA Quarterly Update mailed out
to entities regulated by our office. Per BQA memo 05-013, we will now mail
postcards announcing the latest issue and giving the Internet address to
access the latest Quarterly. Review this and other OQA items via http://dhfs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm.
New OQA Director, Deputy Director
As of September 10, 2005, Cris Ros-Dukler has taken an administrative
health-care position based in Milwaukee. The former Deputy Director, Otis
Woods, has been appointed to replace her as the new director for the
Bureau of Quality Assurance (BQA). His replacement as Deputy Director is
Jane Walters, former chief of BQA's Health Services Section.
Otis Woods has a strong background in surveying and certifying health
facilities, financial management, and budget and policy analysis. He has
worked for the Department of Health and Family Services since 1990. In
1999, Otis began serving as a Quality Assurance Manager and oversaw
provider compliance in community programs. He has been the Deputy Director
of BQA since 2001.
Otis will continue to pursue the goals the Department has set for
protecting the health and safety of residents in health care settings. He
is an effective leader who will continue to improve Bureau regulation
policies and practices throughout all of our regions.
In addition to his many administrative accomplishments, Otis was
selected as a member of the Association of Health Facilities Survey
Agencies in 2003. As part the AHFSA Budget Workgroup, Otis advised the
federal government on resource allocations to state agencies. This work
has resulted in a complete revision of how the federal government
distributes funds to states for survey and certification activities.
Jane Walters holds a Masters Degree in Public Administration and a
Bachelor of Science in nursing degree from the University of
Wisconsin-Oshkosh. As Section Chief of the Health Services Section in the
Bureau of Quality Assurance, she was responsible for the survey, federal
certification, and state licensure of Wisconsin non-long term care
providers, including hospitals, home health agencies, renal dialysis
centers, medical laboratories, and mental health and drug treatment
programs. In addition, she oversaw engineers' inspections of construction
projects and reviews of health facility construction plans.
Before joining BQA in January 2000, Jane served for more that 15 years
as Assistant Director of Nursing, nursing supervisor, and staff nurse at
Winnebago Mental Health Institute (WHMI). In her role as Assistant
Director of Nursing, she was responsible for personnel matters involving
the 325+ nursing department employees, including nursing policy and
procedure development, supervision of the staffing office and house
nursing supervisors, and chaired various committees with WMHI.
Save the Date for FOCUS 2006 Conference
Plan now to attend the 6th Annual Bureau of Quality Assurance (BQA)
Joint Provider/Surveyor Conference, FOCUS 2006, on Wednesday, August 30,
2006. A pre-conference session on elder abuse and sexual assault will also
be held on Tuesday, August 29, 2006. Both events will be held in Appleton,
WI at the Radisson Paper Valley Conference Center.
Caregivers and management from assisted living facilities, nursing
homes, and intermediate care facilities serving people with mental
retardation will benefit from attending the 2006 conference. Additional
information will be provided in the future in upcoming BQA Quarterly
Updates and on the BQA web site at http://dhfs.wisconsin.gov/rl_DSL/Training/index.htm.
A complete conference brochure will be mailed out in late May or early
June 2006.
Enrolling Nursing Home and Assisted Living Residents in Medicare
Prescription Drug Program (Part D)
The Wisconsin Board on Aging and Long Term Care has issued a press
release on the Medicare Part D Prescription Drug Program in a public
service effort to provide facility residents with accurate and timely
information to help them to make wise choices for their future health care
needs. View the press release at http://longtermcare.state.wi.us/home/press
release 12.pdf (exit DHFS; PDF, 94
KB).
Influenza Update
Efficacy and Effectiveness of Inactivated Influenza Vaccine
The main purpose for influenza vaccination is to prevent complications
in those people at highest risk. The effectiveness of inactivated
influenza vaccine depends primarily on the age and immunocompetence of the
vaccine recipient, and the degree of similarity between the viruses in the
vaccine and those in circulation.
Older persons (aged >65 years) with certain chronic diseases might
develop lower post-vaccination antibody titers than healthy young adults,
and thus, can remain susceptible to influenza-related upper respiratory
tract infection. Because of the relatively low efficacy of the vaccine in
preventing influenza illness among the residents, it is important to
remember that confirmed cases among vaccinated residents should NOT be
considered vaccine failures. For older persons residing in nursing homes,
influenza vaccine can be:
- 50%-60% effective in preventing hospitalization or pneumonia, and
- 80% effective in preventing death, but only
- 30% to 40% effective in preventing influenza illness
Algorithm for Long Term Care Facilities
The Wisconsin Division of Public Health (DPH) developed an
algorithm (PDF, 29
KB), "Prevention and Control of Influenza in Long-Term Care
Facilities," to be followed when influenza cases are identified in a
facility. The purpose of this algorithm is to simplify the
response to confirmed cases of influenza within the facility including the
use of antivirals for treatment and prophylaxis. This algorithm is the
official recommendation of the DPH and should be shared with health care
staff, including the Medical Director of the facility.
Outbreaks of influenza should be reported to the local public health
agency. Questions about the algorithm should be addressed to Thomas Haupt
at the DPH. He can be reached at 608-266-5326, or by e-mail at hauptte@dhfs.state.wi.us
You can find additional useful information about influenza at these
sites:
Wisconsin Immunization Registry
Health care providers have a valuable tool available to them with the
Wisconsin Immunization Registry, which provides assistance in ensuring
adults and children are on track with their recommended immunizations.
The Wisconsin Immunization Registry (WIR) is a computerized Internet
database application developed by the Bureau of Communicable Diseases and
Preparedness, Division of Public Health, to track immunization dates of
Wisconsin's children and adults. Over 1,100 state-wide immunization
providers use the WIR, implemented in May, 2000, including physician's
offices, local public health departments, schools, home health agencies,
and other health care facilities.
Registries are important tools for ensuring that people receive their
immunizations according to recommended schedules. Registries will help
prevent over-immunizing, which may occur when health care providers are
unaware of immunizations given by other providers.
The WIR, which received the "Connect Award" earlier this
year, is recognized by the Centers for Disease Control and Prevention
(CDC) as a national model for immunization registries. Health care
providers can use the WIR to track immunizations for patients, residents,
clients and staff. The WIR is provided by the State of Wisconsin at no
cost. For more information, visit http://dhfs.wisconsin.gov/immunization/WIR.htm.
Nursing Homes Required to Vaccinate Residents Against Influenza,
Pneumococcal Disease
On October 7, 2005, the Centers for Medicare and Medicaid Services
(CMS) announced that nursing homes are required to provide immunizations
against influenza and pneumococcal disease to all residents if they want
to continue serving Medicare and Medicaid patients. This requirement is
contained in a final rule published in the Federal Register at http://a257.g.akamaitech.net/7/257/2422/01jan20051800/
edocket.access.gpo.gov/2005/pdf/05-19987.pdf (exit
DHFS).
As a condition of participation in the two programs, nursing homes will
be required to ensure that residents received the immunizations. The
resident or the resident's family can, however, refuse the shots. Also,
residents who cannot receive the vaccines for medical reasons are
exempted. Under the final rule, nursing homes will also be required to
educate the resident and/or the resident's family about the advantages and
possible disadvantages of receiving the vaccines. See the press release at
www.cms.hhs.gov/media/press/release.asp?Counter=1688 (exit
DHFS).
An archived satellite broadcast, titled "Nursing Home
Immunizations," is available at http://cms.internetstreaming.com.
This program provides information regarding medical evidence for nursing
home immunization vaccination, the new MDS influenza and pneumococcal
questions, and the importance of staff vaccinations to protect residents.
For more information on influenza, pneumococcal disease, and vaccinations,
see http://dhfs.wisconsin.gov/rl_DSL/Providers/influenza.htm.
ICF/MRs: Follow up to Vail Hospital Bed Article
The May 2005 BQA Quarterly Update had an article about the FDA alert on
the use of Vail 500, 1000 and 2000 Enclosed Bed Systems. Federal and state
regulations prohibit the use of any type of barred bed in an
intermediate-care facility serving people with mental retardation (ICF/MR),
not just the Vail bed model numbers specified in the FDA alert.
Federal regulation at 42 CFR 483.450(d) (7) discuss "barred
enclosures." This regulation prohibits any bed with bars greater than
three feet in height and any bed with a top. Wisconsin Administrative Code
section HFS 134.60(5)(a)2 defines "physical restraint," and
specifies that any totally enclosed crib or barred enclosure is a physical
restraint.
The physical description of a barred bed enclosure has changed over
time. In 1988, when current state and federal regulations were put in
place, the model was a crib with bars. Today, there are additional types
of enclosed bed designs available, such as beds with mesh sides and
zippers. The regulations prohibit the use of any bed that physically
disallows egress and is intended to confine a client inside the bed in an
ICF/MR. This is the case even when safeguards of assessment, specially
constituted committee approval of individualized program plans, and
informed consent are in place.
If any type of barred bed is currently in use for a client, it is
expected that a plan be immediately put in place to safely move a client
into a non-barred bed. Contact your BQA Regional Field Operations Director
if you have any questions.
Reminder for Informal Dispute Resolution
Staff from the Michigan Peer Review Organization (MPRO) have asked that
the Bureau of Quality Assurance send a reminder to all nursing homes and
facilities for the developmentally disabled that supporting documentation
for Informal Dispute Resolution (IDR) review may not be faxed to MPRO.
MPRO has taken this position for the following reasons.
- Faxed documents often include medical records. While the resident's
name may be blocked out, often the resident's family, physician and
staff's names, or other identifiers are legible. This may be
interpreted as not being compliant with HIPAA standards.
- Often facilities do not confirm receipt of faxed documents. If they
have entered the number incorrectly, they have no assurance that it
has been received by the intended recipient.
- The number of pages and documents being faxed is often prohibitively
large.
Per BQA memo 04-20 [replaced by
08-008], supporting documentation should be mailed to MPRO
at 22670 Haggerty Road, Suite 100, Farmington Hills, MI 48335-2611,
Attention: IDR Review Specialist. Thank you in advance for complying with
the MPRO policy.
BQA Numbered Memos August-October 2005
| Memo |
Title |
Providers Affected |
| 05-009 |
Nurse Aides and Topical
Medication Administration |
Nursing Homes |
| 05-010 |
Variance of
Chapter HFS 124, Wisconsin Administrative Code: Authentication of
Physician Orders |
Hospitals
[OBSOLETE, replaced by 06-006]
|
| 05-011 |
Security Issues
in Psychiatric Treatment Facilities |
Hospitals |
| 05-012 |
UPDATE: Nursing Home
Reporting Requirements for Alleged Incidents of Abuse, Neglect,
& Misappropriation |
Nursing Homes |
| 05-013 |
New Procedure for Disseminating
BQA Information |
Adult Day Care, Adult Family Homes, Ambulatory Surgery Centers,
Certified Mental Health and AODA Treatment Programs, Community Based
Residential Facilities, End Stage Renal Dialysis Units, Facilities
Serving People with Developmental Disabilities, Home Health
Agencies, Hospices, Hospitals, Nurse Aide Training Programs, Nursing
Homes, Outpatient Rehabilitation Facilities, Residential Care
Apartment Complexes, Rural Health Clinics |
| Upcoming Memo: "Wisconsin Coalition for
Person-Directed Care," for nursing homes |
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/.
The following BQA memos have been made obsolete:
- 00-015, "Variance of Chapter HFS 124: Authentication of
Physician Orders" - replaced by memo
05-010
- 00-013, "Security Issues in Psychiatric Treatment
Facilities" - replaced by memo
05-011
- 98-055, "Management of Patients with Antibiotic Resistant
Organisms in a Variety of Health Care Settings" - Guideline has
been revised (Division of Public Health), see article
National Provider Identifier - Medlearn Article
A Medlearn Matters article (SE0005) entitled "Medicare's
Implementation of the National Provider Identifier (NPI): The Second in
the Series of Special Edition Medlearn Matters Articles on NPI-Related
Activities," is now available at www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0555.pdf (exit
DHFS).
The information covered in this article affects providers and suppliers
who conduct HIPAA standard transactions, such as claims and eligibility
inquiries. In addition, organizations and associations that represent
providers and plan to obtain NPIs for those providers should take note of
this article.
In addition, CMS will soon launch a dedicated Medlearn webpage for
Medicare fee-for-service providers on NPI.
Federal Caregiver Background Check Pilot
The Department of Health and Family Services (DHFS) received more than
$2.3 million to participate in a pilot program focused on reducing the
incidence of abuse, neglect, and misappropriation of resident funds
through increased background checks and abuse and neglect prevention
training. Funding for the pilot was included in the Federal Medicare
Modernization Act of 2003. United States Senator Kohl, a long time
advocate of a national caregiver registry, was an important supporter of
the pilot. The pilot is administered by the Centers for Medicare and
Medicaid Services (CMS) in consultation with the U.S. Department of
Justice.
Affected Counties and Start Dates
The pilot affects the following counties over the identified time
period:
- Dane County: March 1, 2006-September 30, 2007
- Kenosha County: January 1, 2006-September 30, 2007
- La Crosse County: February 1, 2006-September 30, 2007
- Shawano County: March 1, 2006-September 30, 2007
Affected Caregivers
The pilot affects all newly hired caregivers in the following provider
types with hiring offices in the pilot counties:
- Community based residential facilities with 9 beds and up,
- Facilities serving persons with developmental disabilities/
intermediate care facilities serving people with mental retardation,
- Home health agencies,
- Hospices,
- Long-term care (swing bed) hospitals,
- Medicaid-funded personal care worker agencies, and
- Nursing homes.
The pilot uses Wisconsin's existing definition of a caregiver. Former
employees and employees under the age of 18 are included in the pilot. Not
included in the pilot are existing staff, staff required to complete their
4-year Caregiver Background Check renewal, volunteers, and students.
New Background Check Process
As part of the pilot, all newly hired caregivers are required to
complete an expanded background check process. The employer can stop the
background check process at any point if disqualifying information is
found. The process includes the following steps:
- Caregiver completes the form HFS-64 Background Information
Disclosure (BID) and Authorization for Release of Federal Bureau of
Investigation (FBI) Information.
- Employer checks free Registries to see if caregiver has any
substantiated incidents of abuse or neglect, including:
- Wisconsin Caregiver Misconduct Registry,
- Office of Inspector General (OIG) Exclusion List, and
- Other state Misconduct Registry, if appropriate.
- Employer completes name-based Caregiver Background Check, which
includes:
- Response from the Department of Justice Wisconsin Criminal
History Record Request name search, and
- A letter from the Department of Health and Family Services that
reports the status of a person's administrative findings or
licensing restrictions.
- Employer makes arrangements for the caregiver to be fingerprinted.
- Caregiver attends fingerprint appointment.
- Fingerprints are checked against Wisconsin's criminal records and
FBI criminal records.
- Fingerprint results are sent back to the employer via DOJ's Criminal
History Record Request website.
- Employer makes hiring decision.
Wisconsin is using pilot funds to cover the added fees associated with
the fingerprint background check. Affected providers will continue to pay
the fee for the name-based Caregiver Background Check, with the exception
of Medicaid-funded personal-care-worker-only agencies.
Abuse and Neglect Prevention Training
The pilot also includes abuse and neglect prevention training. This
training will be provided free of charge in each of the pilot counties.
Unlike the background check process, which only affects newly hired
caregivers, the training will be open to all caregivers. The training will
include experiential training, which will give participants a unique
opportunity to learn by "walking in the shoes" of another member
of the long-term care community. In addition, workshops will provide
strategies for behavior and interventions related to abuse and neglect
prevention.
For more information about the pilot, see http://dhfs.wisconsin.gov/caregiver/fedBCpilot.htm.
Revised Guidelines for Prevention, Control of Antibiotic-Resistant
Organisms
The Wisconsin Bureau of Communicable Diseases and Preparedness (BCDP)
has revised its guidelines for managing patients with antibiotic resistant
organisms, in order to include updated information. The new publication,
entitled "Guidelines for Prevention and Control of Antibiotic
Resistant Organisms in Health Care Settings," replaces the 1998
manual, "Management of Patients with Antibiotic Resistant Organisms
in a Variety of Health Care Settings." The revised guidelines are at http://dhfs.wisconsin.gov/communicable/resources/pdffiles/AROguidePPH42513_0905.pdf.
The most significant changes in the new guidelines are:
- The guidelines promote the use of active surveillance culture for
certain circumstances in some health care settings.
- The ability to "clear" a person with a past history of
antibiotic resistant organisms by use of three negative cultures has
been eliminated.
- Use of alcohol gel as the primary method of hand hygiene is
encouraged.
Nursing Homes: Revised Appendix P of the State Operations Manual
These changes were mentioned in Survey & Certification letter
05-34, "Issuance of Revisions to Appendix P, SOM, Survey Protocol for
LTC Facilities," issued earlier this year. Transmittal 9 of the State
Operations Manual (SOM), "Revision of Appendix P and certain Exhibits
of the State Operations Manual," can be found at www.cms.hhs.gov/manuals/pm_trans/R9SOM.pdf (exit
DHFS).
This revision of Appendix P introduces the new Quality Indicators
Survey (QIS) as a second type of survey-of-record, introduces the new
Quality Measure/Quality Indicator (QM/QI) Reports for surveyor use, and
makes a few other minor changes to text and selected exhibits. Throughout
Appendix P, the phrase "Quality Indicator Report(s)" was
replaced with "Quality Measure/Indicator Reports" (or their
abbreviations) to reflect the change in the title of these reports.
Appendix P is also located at www.cms.hhs.gov/manuals/107_som/som107_appendixtoc.asp
(exit
DHFS)
as both a PDF document and a zipped Word file.
New RAI/MDS Education Coordinator
The Bureau of Quality Assurance (BQA) is pleased to announce that
Therese VanMale has been hired as the new RAI/MDS Education Coordinator in
the Provider Regulation and Quality Improvement Section. Therese will be
the Bureau's point of contact for nursing facilities with questions or
concerns regarding the Resident Assessment Instrument (RAI) and Minimum
Data Set (MDS). Therese will also conduct provider training programs for
nursing facility staff around the state, and serve as the Bureau's liaison
to CMS and to Metastar, the Wisconsin Quality Improvement Organization (QIO),
on issues regarding the RAI and MDS.
Therese comes to her new position from the Bureau's Milwaukee Regional
Office, where she was a long term care surveyor in the Resident Care
Review Section since 2001. Prior to joining state service, she worked as a
staff nurse and quality improvement coordinator in Wisconsin nursing
facilities. Therese earned her Associate's Degree in Nursing in 1993 from
Nicolet Area Technical College, and a Bachelor's Degree in Nursing from
the University of Wisconsin - Green Bay in 1999. She assumed her new
duties in BQA on September 19, 2005.
Therese can be reached by telephone at 608-266-7188 or via email at VanMaTA@dhfs.state.wi.us.
Please join us in welcoming Therese to her new position.
MDS Automation Provider Training Opportunity
BQA is sponsoring a provider training program for MDS automation
issues. The program will be held on December 8, 2005, at the Comfort Inn
in Madison. This program will include instructions for electronically
submitting MDS assessment records to State MDS System, printing and
interpreting MDS validation reports, the MDS Correction Policy, and
accessing CASPER reports including the new QM/QI reports. A brochure
regarding this training, including registration information, has been
mailed to all WI nursing homes, and this brochure is also posted under the
Bulletins area of the State MDS System Welcome page.
Revisions to the RAI Manual 2.0
The August 2005 Revisions to the RAI Manual 2.0 are now available on
the CMS MDS 2.0 website. Updates can be viewed and downloaded at http://cms.hhs.gov/quality/mds20
(exit
DHFS) [address updated].
The revisions include the new Section W, which consists of the National
Provider ID and Influenza and Pneumococcal Immunization items. A second
release is expected in November, deploying the new RUGS 53 grouper.
MDS QM/QI Reports
This is a reminder that the MDS QI reports have been moved to the
CASPER System. Nursing homes access CASPER using a link on the State MDS
Welcome Page. Training material regarding the new MDS QM/QI reports can be
obtained from the State MDS Welcome Page and from the QIES Technical
Support Office Website under the MDS link at http://www.qtso.com (exit
DHFS).
The MDS Monthly Quality Indicator Comparison Report has also been moved
to CASPER. Previously, this report was generated on the 28th day of each
month and was stored on the State MDS System in the same location as the
MDS Validation Reports. Nursing homes must now use CASPER to generate the
new Quality Measure/Indicator Monthly Compare Report and may specify date
ranges to be included in the report. This report conforms to privacy rules
for protecting the confidentiality of resident information. This is the
only MDS QM/QI report that nursing homes may share with consumers. For
additional information regarding this report, refer to the 2001 CMS
memorandum S&C 01-17, which can be accessed at the following CMS
website: www.cms.hhs.gov/medicaid/survey-cert/050301b.asp [no longer
operable].
Changes to the CMS State Operations Manual for Home Health Agencies
On August 12, 2005, CMS published Transmittal 11 for Pub 100-07,
announcing revisions to the State Operations Manual (SOM) for home health
agencies (HHAs) to include current CMS policy memorandum, delete material
and reference forms that are obsolete, and make minor editorial changes
within Chapter 2, §2180E thru §2200F. Appendix B Interpretive Guidelines
were also revised. These changes are not yet on the Internet versions, so
we recommend that agencies view Transmittal 11 at www.cms.hhs.gov/manuals/pm_trans/R11SOM.pdf (exit
DHFS).
BQA Wins AHFSA Award
Wisconsin Bureau of Quality Assurance won first place for Promising
Practice in the Open Category from the Association of Health Facility
Survey Agencies (AHFSA). Wisconsin won for its submission, "Assisted
Living Start-Up Information Available on Web." Kevin Coughlin,
Section Chief, accepted the award at the AHFSA annual conference in
Albuquerque, New Mexico, on October 10th.
Growth in assisted living continues at a rapid pace, and it is
important to allow prospective assisted living providers easy access to
important information to assist them in the development of their assisted
living facility. This information is presented in the "Starting
Up" pages for the various facility types accessed via http://dhfs.wisconsin.gov/rl_DSL.
In addition, these pages have helped BQA streamline operations during
tight budget times by allowing staff to quickly refer applicants to
accessible information instead of explaining the processes themselves.
Wisconsin in National Report on Assisted Living Facilities
The National Academy for State Health Policy, of the U.S. Department of
Health and Human Services, issued a report, "State Residential Care
and Assisted Living Policy: 2004," which portrays Wisconsin as a
progressive state with favorable funding strategies and regulatory
oversight for Assisted Living/Residential Facilities.
Some highlights from the report:
- Wisconsin continues to experience higher than average growth in
assisted living facilities.
- The survey process, including technical assistance and abbreviated
survey, is highlighted.
- The Assisted Living Forum.
- The process used to change the regulations is mentioned (HFS 83
rewrite).
- Wisconsin regulations include language related to assisted living
philosophy and negotiated risk.
- Wisconsin's state website.
- Wisconsin is one of only eight states that use both Medicaid waivers
and the state plan when using Medicaid to cover services in
facilities.
The report can be viewed online at http://aspe.hhs.gov/daltcp/reports/04alcom.htm (exit
DHFS).
Food and Drug Administration Releases 2005 Food Code
On September 23, 2005, the FDA released the 2005 edition of the
"Food Code and a Summary of Changes." The Food Code has been
revised every two years, with the exception of 2003, since its inception
in 1993. Federal and state healthcare agencies reference the Food Code as
a standard of practice for storing, preparing, distributing, and serving
food under sanitary conditions to prevent the spread of food borne
illness. It is online at www.cfsan.fda.gov/~dms/fc05-toc.html (exit
DHFS).
The Code provides practical, science-based guidance and manageable,
enforceable provisions for mitigating risk factors known to cause
foodborne illness. It contains recommendations reflecting current science,
emerging food safety issues, and the 2004 Conference for Food Protection
recommendations.
The Food Code 2005 Summary of Changes at www.cfsan.fda.gov/~dms/fc05-sum.html
(exit
DHFS)
provides a synopsis of the changes made beyond the 2001 Food Code and a
Food Code Supplemental of 2003.
Ensuring safe food remains an important public health priority. For
some consumers, especially older adults and those with impaired immune
systems, foodborne illness may have serious or long-term consequences, and
may be life threatening.
The Food Code is viewed by BQA as a recognized standard of practice
document. We urge all healthcare facilities to familiarize themselves with
it, and use it when developing and revising food handling policies and
procedures and training staff. Note that the Food Code is referenced in
federal nursing home regulations at 42 CFR 483.35 (F-tag 371).
Latest CMS Survey & Certification Letters
Below is a list of selected Survey and Certification (S&C) Letters
distributed by CMS during the last quarter. Titles pertaining only to
state agency operations are omitted. All S&C Letters can be viewed as
PDF files at the Internet site www.cms.hhs.gov/medicaid/survey-cert/letters.asp
[Site Changed, see letters below] .
If you have questions about individual letters, contact Susan Hespen of
BQA at (608) 266-0582, or e-mail hespesj@dhfs.state.wi.us.
Nursing Home Compliance with Abuse Prevention Requirements
S&C Letter 05-46, located at www.cms.hhs.gov/medicaid/survey-cert/sc0546.pdf
(PDF; exit DHFS), reminds all Medicare and Medicaid
participating nursing homes of the federal requirements related to
screening potential employees and checking with all appropriate nurse aide
registries. This memorandum also provides contact information for nurse
aide registries in every state.
Long-Term Care Facilities Smoke Detection Questions & Answers
These questions and answers are in response to CMS S&C Letter
05-25, on the Internet at www.cms.hhs.gov/medicaid/survey-cert/sc0525.pdf
(PDF; exit DHFS).
Q: If my nursing home currently does not have corridor smoke detection
and is not fully sprinkler protected, will I be required to install smoke
detection by May 24, 2006?
A: Yes. CMS Memo 05-25 clarifies that all nursing homes that are not
fully sprinkler protected are required to install smoke detection in all
common areas which includes corridors. The detectors can be at minimum,
battery operated, yet the time frame until May 24, 2006 was established to
encourage system connected detectors.
Q: A nursing home is not fully sprinkler protected; explain what
"common" areas entails and give a few examples?
A: CMS Memo 05-25 states that, for not fully sprinkler protected
nursing homes, additional smoke detection is required for all resident
rooms and common areas. Examples of common areas include a corridor,
activity space, chapel, or physical therapy type spaces. Common areas are
used on a frequent basis by a large number of residents. Common areas
would not be anticipated to include a staff office, staff break room, or a
small resident treatment room.
Q: A nursing home is not fully sprinkler protected; explain what
additional planning is anticipated with the use of battery operated smoke
detectors?
A: Additional planning would include a maintenance program for the
battery operated smoke detectors per the manufacturer's recommendations.
This planning typically includes a weekly test with the batteries being
changed at least semi-annually. Different frequencies may be permitted if
they are in accordance with the manufacturer's recommendations.
Q: A nursing home is not fully sprinkler protected; explain how the
facility's fire plan would be modified if battery operated smoke detectors
were used?
A: The facility's fire plan should state that upon staff recognizing a
battery operated smoke detector activation, the expectation is that staff
shall respond by activating the facility wide fire alarm system without
delay.
Administrative Rules Update
HFS 83 - "Community Based Residential Facilities"
The HFS 83 re-write workgroup, working with providers and association
representatives, has finalized the draft of the proposed rules for Chapter
83. The Rule Summary and draft rule are currently under review with the
DHFS Office of Legal Council. You may view the Statement of Scope of
proposed rules on the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov (exit
DHFS) for more information.
HFS 124 - "Hospitals"
The Wisconsin Administrative Register published a Statement of Scope of
proposed rules to amend Chapter 124 on April 1, 2005. The Department is
planning to update Ch. 124 to eliminate overly prescriptive regulations,
clarify the Department's enforcement authority, and make the rule more
consistent with the federal Medicare requirements. For more information,
view the Statement of Scope on the Wisconsin Administrative Rules website
at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 132 - "Nursing Homes"
BQA convened an internal workgroup to update HFS 132 to reflect
standards of care and practice, and to eliminate duplicative state
regulations that are already in Wisconsin Statutes, Chapter 50, and the
federal nursing home regulations. The intent is to streamline the code by
eliminating duplicative regulations that provide unnecessary specificity
and adopt the applicable federal regulatory language. The proposed rule
changes are currently under review by interested stakeholders. For more
information, view the Statement of Scope on the Wisconsin Administrative
Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 133 - "Home Health Agencies"
The HFS 133 re-write workgroup met with an advisory committee
consisting of providers, consumers, and association representatives to
develop proposed rules to amend HFS 133. The goal of the committee is to
amend the rule to make the requirements more consistent with federal
regulations and to reflect current terminology. The workgroup is in the
process of drafting the proposed rule for submission to DHFS Office of
Legal Council for review. For more information, view the Statement of
Scope on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov (exit
DHFS).
HFS 148 - "Cancer Drug Repository Program"
Governor Doyle signed Act 16 creating the Chronic Disease Repository
program to include prescription drugs and supplies for chronic disease and
to submit proposed rules by May 1, 2006. Assembly Bill 197 expanded HFS
148--Cancer Drug Repository Program to include prescription drugs and
supplies for chronic disease. BQA staff are developing a Statement of
Scope and will draft an amended proposed rule, Chapter 148, Cancer and
Chronic Disease Drug Repository Program, to be effective May 1, 2006.
For additional information, you may view the BQA Cancer Drug Repository
website at http://dhfs.wisconsin.gov/bqaconsumer/cancerdrugreposy.htm.
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Last Revised: June 30, 2008 |
