DQA Quarterly Information Update

January 2003

[PDF Version of this month's Quarterly Update (PDF, 129 KB) - blue text indicates links to other sections or to Internet pages]

• Staff Changes in the Bureau of Quality Assurance

• Upcoming BQA Office Move

• BQA Numbered Memos Posted October-December 2002

• Assisted Living Directories on the Internet

• Upcoming Seminar/Training Opportunities

• Satellite Training on OASIS Changes

• Wisconsin Health Facility Fire Information for 2001

• Fire/Smoke Damper Recall

• Latest CMS Survey & Certification Letters

• Bureau of Quality Assurance (BQA) Administrative Rules Update

• Wisconsin Nurse Aide Registry and Competency Testing Services Update

• Updated RAI User's Manual for MDS

• Changes to the DHFS Website

Staff Changes in the Bureau of Quality Assurance

We are very pleased to announce the appointment of Michael (Mike) Steinhauer, OT, MPH, FAOTA as the new Chief of the Resident Care Review Section for BQA. Mike will begin his duties on January 6, 2003. Mike joins us from his position as the Executive Director of the Wisconsin Occupational Therapy Association. His background includes more than 25 years of direct health care and senior management experience, including being a national Director of Quality Compliance/ Accreditation Affairs for 463 home health agencies in 22 states. He has a wealth of knowledge of both federal and JCAHO health care rules and regulations. He has authored numerous publications and received a number of national awards in the occupational therapy field. Please join BQA in welcoming Mike to our staff! Many thanks also to Kevin Coughlin for having served as interim Chief.

Upcoming BQA Office Move

Two BQA sections will be relocating to a new home in January, the Health Services Section (HSS) and the Caregiver Regulation & Investigation Section (CRIS). CRIS includes the Wisconsin Nurse Aide Training, Testing & Registry Program as well as the Caregiver Background Check program. HSS conducts federal certification and state licensure surveys and complaint investigations of ambulatory surgery centers, comprehensive outpatient rehabilitation facilities, end stage renal disease units, home health agencies and hospices, hospitals, prospective payment exemption programs, outpatient rehabilitation agencies, rural health clinics, and swing bed units (hospitals). HSS engineering staff are responsible for conducting new construction and renovation plan reviews and onsite inspections of hospitals, ambulatory surgical centers, community-based residential facilities and end stage renal disease facilities. The Program Certification Unit in HSS conducts state certification surveys and complaint investigations of the state’s alcohol and other drug abuse and mental health programs. Here is the new address and telephone number information:

BQA Numbered Memos Posted October-December 2002

Access BQA memos via www.dhfs.state.wi.us/rl_DSL/Publications/ BQAnodMems.htm for all memos or individual providers' Publications pages via www.dhfs.state.wi.us/licensing.htm.

Please note that language was corrected in BQA memo 02-013, Informal Dispute Resolution, in order to clarify use of the IDR request form.

The notice we had in the previous BQA Quarterly Update about a projected memo regarding Certification of County-Private Contracted Mental Health and AODA Programs has been made a Division of Supportive Living memo DSL 2002-016 located at www.dhfs.state.wi.us/dsl_info/NumberedMemos/DSL/CY_2002/ NMemo2002-16.htm.

Assisted Living Directories on the Internet

We are very pleased to announce the Internet posting of directories for Community Based Residential Facilities (CBRFs), Adult Family Homes (AFHs) and Residential Care Apartment Complexes (RCACs) at www.dhfs.state.wi.us/bqaconsumer/ AssistedLiving/AsLivPrvdr.htm. These PDF and Excel files will be updated monthly (CBRFs and AFHs) and quarterly (RCACs, along with Adult Day Care programs).

We are working on providing Internet-accessible directories for nursing homes, hospitals, home health agencies, and the like. Hard copies of directories (generated quarterly) will continue to be available for a charge by calling (608) 266-8481.

Upcoming Seminar/Training Opportunities

Brochures on upcoming training will be mailed to providers and posted on the Internet. Check the Provider or What's Happening sections for individual health care providers on the DHFS Website www.dhfs.state.wi.us via the Licensing pages. For registration questions, contact the Bureau of Quality Assurance Training Coordinator at (608) 267-1438.

Satellite Training on OASIS Changes

On November 22, 2002, CMS broadcast a satellite training to explain and answer questions on proposed Outcome and Assessment Information Set (OASIS) changes and enhanced home health agency survey protocol guidelines. The program was intended for home health agencies, home health provider associations, state and regional offices. You can go to the webcast site at http://(www)cms.internetstreaming.com/ (exit DHFS) and view this broadcast until 11/22/04. The program is also available as a video for purchase by calling 703 605 6186. The OASIS changes are summarized in the CMS S&C letter at www.dhfs.state.wi.us/rl_DSL/HHAs/ scltr02-41.pdf (exit DHFS, PDF - address changed).

Wisconsin Health Facility Fire Information for 2001

Here is a table of information about fires reported to BQA from Wisconsin health and residential care facilities for the year 2001:

We expect that data for 2002 will become available in March, 2003.

All fires in a licensed health or residential care facility in Wisconsin must be reported within 72 hours to the Department of Health & Family services. You may use the Fire Report form located on the Internet at www.dhfs.state.wi.us/forms/DSL/ dsl2500.pdf (PDF, 23 KB) and fax it to (608) 267-7119 or to the appropriate BQA Regional office (see www.dhfs.state.wi.us/rl_DSL/Contacts/reglmap.htm). See also BQA memo 00-017 posted at www.dhfs.state.wi.us/rl_DSL/Publications/ 00-017.htm.

Fire/Smoke Damper Recall

In cooperation with the U.S. Consumer Product Safety Commission (CPSC), Invensys Building Systems, of Love Park, Ill., is recalling up to 560,000 Siebe actuators for testing and replacement, if necessary, which could be found in fire and smoke dampers. Actuators hold open fire and smoke dampers in a building's heating, ventilation and air conditioning (HVAC) system. A spring mechanism, integrated with the damper, is designed to close the damper during a fire to limit the spread of smoke, fire and fumes. The recalled actuators can jam and prevent the dampers from closing. If dampers fail to close during a fire, smoke, fire and fumes can spread through a building's ventilation system and cause serious injury or death.

These MA-200 and MA-200-1 series actuators, used in fire and smoke dampers manufactured by various companies from December 1993 through October 1999, were installed by private contractors in commercial and residential buildings. The actuators have manufacture date codes of 9348 through 9947. Building owners and managers whose buildings have dampers containing Invensys/Siebe actuators should immediately contact Invensys's Program Coordination Office at (877) 481-2372 between 7 a.m. and 7 p.m. CT Monday through Friday. Building owners can obtain a complete copy of the program information via www.regcen.com/MA200. Also see www.cpsc.gov/cpscpub/prerel/n prhtml03/03003.html (exit DHFS) for the U.S. Consumer Product Safety Commission release.

Latest CMS Survey & Certification Letters

Below is a list of the Survey and Certification Letters distributed by the Centers for Medicare and Medicaid Services (CMS) during the last quarter. Please be aware that some letters pertain only to state agency operations. If you have questions about individual letters, contact Susan Hespen of BQA at (608) 266-0582 or E-mail hespesj@dhfs.state.wi.us.

Bureau of Quality Assurance (BQA) Administrative Rules Update

HFS 83 - "Community Based Residential Facilities" (CBRFs)

• BQA internal workgroup is drafting new language for the rulemaking order.

HFS 124 - "Hospitals"

• BQA internal workgroup continues to draft and review rules for the rulemaking order.

HFS 129 - "Certification of Programs for Training and Testing Nurse Assistants, Home Health Aides and Hospice Aides"

• Statement of Scope to be published in the WI Administrative Register about mid to late January 2003.

HFS 132 - "Nursing Homes"

• The BQA internal workgroup is drafting rules that are subject to the Statement of Scope.

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

Wisconsin Nurse Aide Registry and Competency Testing Services Update

The Department of Health and Family Services has implemented a state-administered competency test, as allowed under federal law, to ensure a neutral and objective testing process. The Department has awarded the contract for the Wisconsin’s Nurse Aide Registry and Competency Testing services to Promissor (formerly CAT*ASI), a recognized leader in the development and delivery of state certification testing and record management for nurse aides, insurance and real estate agents.

The Wisconsin Nurse Aide Candidate Handbook provides nurse aide candidates with detailed instructions regarding the competency test process (the Written or Oral Examination and Skills Evaluation), scheduling information, and Registry issues. The approved Wisconsin Nurse Aide Candidate Handbook is now available on Promissor’s website (select "Testing Services," select "nurse aides," then scroll to "Wisconsin Nurse Aides").

The following approved versions of the Wisconsin Nurse Aide Competency Evaluation and Registry forms are now also available on Promissor's website (exit DHFS):

• Application for Competency Evaluation
• Out-of-State Application
• Change or Correction Form
• Registry Renewal Form
• Medication Aide Registry Application

The Wisconsin Nurse Aide Testing Services (WNATS) has approved in-facility and regional test site applications throughout the state. The test sites meet state and federal nurse aide training and testing program requirements. WNATS processes completed Competency Evaluation Application forms within 48 hours. A competency test is promptly scheduled at either an in-facility or regional test site. WNATS must schedule the initial competency test within 120 business days of enrollment in the nurse aide training program.

In-Facility Test Sites: An in-facility test site is generally a facility that sponsors a nurse aide training program and has been approved for competency test administration. WNATS will contact the training program and arrange a mutually acceptable date and time for testing. A nurse aide evaluator will be assigned to administer the competency test at the facility.

Regional Test Sites: Regional test sites and schedules are established throughout Wisconsin. WNATS schedules a candidate for testing at the closest regional site when in-facility testing is not available.

If you are a nurse aide, training program, or health care provider who employs nurse aides, please call the Wisconsin Nurse Aide Testing Service toll-free (877) 290-3499 if you have questions about:

• Nurse aide testing process
• Scheduling an examination
• Applying to be a nurse aide evaluator
• Applying to be a regional or in-facility test site

If you are a nurse aide or health care provider who employs nurse aides, please call the Wisconsin Nurse Aide Registry IVR, toll-free (877) 224-0235 or check Promissor's website at www.promissor.com (exit DHFS), click on "Other Services," click on "Registry Services," click on "Nurse Aides," then scroll to "Wisconsin Nurse Aides" to verify a nurse aide’s registry status.

Please call the Wisconsin Nurse Aide Registry toll-free at (877) 329-8760 if you have questions about:

• Reporting a nurse aide’s current address
• Nurse Aide Registry renewal process
• Nurse Aide Registry forms

Please call the Caregiver Regulation and Investigation Section at (608) 261-7650 (after February 3, 2003, call (608) 243-2019) or e-mail at Caregiver_Intake@dhfs.state.wi.us, if you have questions about:

• Federal or state nurse aide guidelines
• Substantiated findings on the Caregiver Misconduct Registry

Please note that the E-mail address Wi_Nurse_Aide_Directory@dhfs.state.wi.us is being taken down. We will no longer accept any messages sent to this address. Correspondents will be directed to E-mail Caregiver_Intake@dhfs.state.wi.us instead.

Please be sure to frequently check the Department’s website for the latest news on the Wisconsin Nurse Aide Competency Testing and Registry services and quick links to Promissor's website. The Bureau will also post a Frequently Asked Question document to address issues that have been raised. The address is www.dhfs.state.wi.us. Click on "Licensing-Health/Medical Care" and then on "Nurse Aide Training and Registry."

Updated RAI User's Manual for MDS

The updated version of the 1995 Long Term Care Resident Assessment Instrument (RAI) User's Manual for the Minimum Data Set (MDS) became effective January 1, 2003. This updated version incorporates clarifications to existing coding and transmission policy, integrates Questions and Answers (Qs & As) into the appropriate sections and addresses requested clarifications and scenarios concerning problem areas. This manual has been posted to the CMS web site at http://cms.hhs.gov/medicaid/mds20 (exit DHFS).

All RAI/MDS Manual users, including providers and state surveyors, should start using the updated manual. Per public comment, the new Swing Bed-MDS that became effective May 2002, was not incorporated into this revision of the RAI/MDS Manual.

Changes to the DHFS Website

If you have browsed through the Department of Health and Family Services' Internet site recently, you may have noticed the changes to the Programs & Services and the Licensing home pages. Viewers seeking information on provider regulation must now choose between "Licensing – Health / Medical Care" and "Licensing – Residential / Community Based Care" from the main Licensing page. Some provider types, such as Nurse Aide and Home Health pages are available from both. The Programs & Services page has been similarly reorganized.

The Department continues to work on reorganizing the DHFS Internet site, and further changes will be forthcoming in the next few weeks. We hope that these changes will help viewers in locating information they need.

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