DQA Quarterly Information Update

November 2004

[PDF Version of this month's Quarterly Update (PDF, 103 KB) - blue text indicates links to other pages or Internet sites]

• Staff Changes
• Requirement to Submit 4 Year Renewal of Caregiver Background Check Information on BQA License Holders
• Effective Dates for Medicare Enrollment – Nursing Homes
• Appendix N Deleted from State Operations Manual
• Informal Dispute Resolution Process – Important Information
• Consumer Information Reports 2003
• Statewide Variances: Nurse Prescribers, Employee Requirements
• Patient and Client Rights: Division Memo, New Home Health Form
• New Internet Sites: Feeding Assistants, Medication Aides, Caregiver Background Check Process
• BQA Numbered Memos July-October 2004
• Upcoming Division of Disability and Elder Services Memos
• New Resident Care Review Section Region Boundaries
• Reminder Regarding Resident Choice
• Influenza and Pneumococcal Vaccinations
• Critical Access Hospitals (CAHs)
  • CMS Observation Bed Clarification
  • Waiver of HFS 124.40 (2)(c)
  • Waiver of HFS 124.40 (2) (a) & (b) for Distinct Part Units
  • Certificate of Approval Re-issued
• Latest CMS Survey & Certification Letters
• Life Safety Code Clarification of Corridor Width
• Physician Rubber-Stamped Signatures in Home Health Agencies and Hospices
• Upcoming Training
• OASIS (Outcome and Assessment Information Set) Information
  • OASIS Resources
  • CMS Policy Change for Accurate Coding of OASIS Pressure Ulcer Items
  • OASIS Certificate and Competency Board
  • OASIS Assessment Requirement Changes
  • OASIS Workshops
• Administrative Rules Update
• Data Accuracy - Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Training Initiatives

Staff Changes:

We are sorry to announce that Susan Larsen, Director of the Office of Caregiver Quality, will be leaving BQA as of October 1, 2004. She has accepted an appointment to manage the Federal Criminal Background Check Pilot. While we lose a very dedicated, valued and successful program manager, we will continue to communicate with Sue in her new assignment at the national level.

Sue has been with BQA since 1999 and was instrumental in successfully implementing Wisconsin's Caregiver Program, which served as a model for the Federal Criminal Background Check Pilot. Sue also helped set up the Promissor Contract to standardize nurse aide training across the state and ensuring that we are efficient in investigating misconduct allegations.

Effective October 1, 2004, Michael Steinhauer is no longer with the Bureau of Quality Assurance. Michael had been with BQA since January 2003. During that time, Michael was instrumental in a number of changes in the Bureau’s oversight of long term care facilities. In the interim, all inquiries regarding nursing homes and intermediate care facilities for persons with mental retardation should be sent to Cris Ros-Dukler, Director of BQA. Ms. Ros-Dukler’s telephone number is (608) 267-7185.

We are very pleased to announce Paul Peshek’s promotion to the Regional Field Operations Director position in the Northeastern Regional Office, Review Care Section (nursing homes and intermediate care facilities for persons with mental retardation). Paul came to BQA last year as a Regional Field Operations Supervisor in the Southern Regional Office in Madison. Prior to that, he served as an Administrative Policy Advisor for the Division of Care and Treatment Facilities before it was merged into the Division of Disability and Elder Services. He has served in a variety of supervisory and administrative positions, including those of nursing home administrator, in a range of facilities including skilled nursing, intermediate care for the developmentally disabled, and assisted living in Wisconsin and Indiana. Please join us in welcoming Paul to his new responsibilities.

Notice of Requirement to Submit 4 Year Renewal of Caregiver Background Check Information on BQA License Holders

Entities regulated by the Bureau of Quality Assurance (BQA) received a memo dated July 15, 2004 which served as notice to the entity license holders/legal representatives that the Bureau of Quality Assurance is conducting the required four-year renewal of caregiver background checks. Individuals were required to comply with the notice by August 15, 2004.

Some BQA-regulated entities have not complied as required. Pursuant to s. HFS 12.05, Wis. Admin. Code, failure to comply with any provision of background information gathering required by s. 50.065, Stats. may subject an entity to certain sanctions, including denial, revocation, nonrenewal or suspension of regulatory approval. To avoid these sanctions, entities that have not complied with this requirement must submit the required paperwork at this time.

Providers may access the BQA Regulated Entity Background Check Process web page at http://dhfs.wisconsin.gov/caregiver/fouryear.htm to obtain the necessary forms for the Existing License Holder Four-Year Renewal Background Check Process. The completed Background Information Disclosure, Appendix and fee for the license holder/legal representative, appropriate board members and nonclient residents should be submitted to BQA. Do not submit forms or fees for employees.

Please contact the Office of Caregiver Quality by e-mail at Caregiver_Intake@dhfs.state.wi.us or by phone at (608) 243-2019 with questions regarding this requirement.

Effective Dates for Medicare Enrollment – Nursing Homes

The Centers for Medicare & Medicaid Services have requested any nursing home seeking enrollment in the Medicare program to identify in writing, along with their application, the date it wants the certification to become effective. An effective date cannot be prior to the approval date of the CMS 855A or the date of compliance when an initial survey is conducted. Contact Gail Hansen at (608) 266-2966 for questions regarding Medicare certification.

Appendix N Deleted from State Operations Manual

As of June 1, 2004, the Centers for Medicare and Medicaid Services (CMS) pulled and deleted Appendix N of the State Operations Manual affecting nursing homes and intermediate care facilities for persons with mental retardation. This appendix contained guidelines for surveyors to look at specific medications and how these facilities monitored them. Some of the material in Appendix N had been incorporated in Appendix PP. For more information about this and other changes to the State Operations Manual, see CMS Manual System Transmittal 1, May 21, 2004 at www.cms.hhs.gov/manuals/pm_trans/R1SOM.pdf (exit DHFS; PDF 104 KB).

Informal Dispute Resolution Process – Important Information

Nursing homes and intermediate care facilities for persons with mental retardation that request an Informal Dispute Resolution (IDR) need to be aware of the following items. Please refer to BQA memo 04-020 at http://dhfs.wisconsin.gov/rl_DSL/Publications/04-020.htm published in July [replaced by 06-005].

1. The Wisconsin IDR Service Agreement with MPRO is located at http://dhfs.wisconsin.gov/rl_DSL/Publications/pdfmemos/ 04-020attC.pdf – Many people have stated that they could not locate this agreement. It is included and accessible as an attachment to BQA memo 04-020.
2. On the Informal Dispute Resolution Request form DDE-2514, entities have been failing to include the date they receive the Statement of Deficiencies (SOD). This is crucial information. Failure to note this information may result in delays in processing your IDR request during an already tight timeframe.
3. Supporting documentation is an important AND REQUIRED component of your IDR request. Item (1)(b) reads as follows: "(b) Any request for IDR that is received between the fourth and tenth calendar day following receipt of the SOD will be honored, but the IDR will be limited to a desk review of the contested citations and the facility's supporting documentation. ..." (emphasis added). What this means is that if supporting documentation is NOT provided by Day 10, the IDR will not happen. IDRs will not be conducted using the SOD alone. Supporting documentation needs to be submitted by Day 10 for the IDR to proceed.

Please review BQA memo 04-020 if you have any questions concerning the IDR process. Phone numbers are available for any questions you may have.

Consumer Information Reports 2003

We have posted the 2003 Consumer Information Reports for Wisconsin nursing homes and intermediate care facilities for persons with mental retardation at http://dhfs.wisconsin.gov/bqaconsumer/NursingHomes/ CIRindex.htm. These will be the full version instead of the summary sheets that were mailed to facilities in August.

Statewide Variances: Nurse Prescribers, Employee Requirements

Certified mental health and substance abuse treatment program providers: please be sure to review BQA memos 04-024 and 04-027 concerning statewide variances of Wisconsin administrative rules regarding employee qualifications. You may access both memos via http://dhfs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm.

The Department has decided to recognize the role of Advanced Practice Nurse Prescribers (APNPs) in mental health outpatient treatment and community supported programs. BQA memo 04-024 describes the background of this decision and the requirements necessary to allow APNP employment in these programs.

Similarly, a variance has been granted concerning social workers, professional counselors, and marriage and family therapists (Chapter MPSW 3, Chapter MPSW 11, and Chapter MPSW 16). Refer to BQA memo 04-027 concerning this variance, its limits and requirements.

Patient and Client Rights: Division Memo, New Home Health Form

The July 2004 Quarterly Information Update announced the new Client Rights Internet site at http://dhfs.wisconsin.gov/clientrights/index.htm. The Division of Disability and Elder Services has since put out a DDES Info Memo at http://dhfs.wisconsin.gov/dsl_info/InfoMemos/DDES/CY_2004/ InfoMemo2004-05.htm. Please review this memo for information on client and patient rights, guardianship, confidentiality of treatment records, and other material that can be obtained from this Internet site.

In addition, the new Home Health Patient Rights form (English and Spanish versions) is now available on the DHFS Internet site at http://dhfs.wisconsin.gov/forms/DDES/DDE2601.pdf (PDF 14 KB).

New Internet Sites: Feeding Assistants, Medication Aides, Caregiver Background Check Process

The Bureau has added three the following three new Internet sites:

• BQA Regulated Entity Background Check Process http://dhfs.wisconsin.gov/caregiver/CBCprocess.htm
• Wisconsin’s Feeding Assistant Program
  http://dhfs.wisconsin.gov/caregiver/FeedingAssistant/ FeedingAsts.htm

• Nursing Home Medication Aides in Wisconsin
  http://dhfs.wisconsin.gov/rl_DSL/NHs/MedAides.htm

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BQA Numbered Memos July-October 2004

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 obsoleted the following BQA memos:

• 03-013, replaced by BQA 04-020.
• 99-044 and 99-045, superseded by Client Rights at http://dhfs.wisconsin.gov/clientrights.

• These two memos are now obsolete for nursing homes: 93-003 and 94-030, per BQA memo 04-022. They are however still applicable for home health agencies.

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Upcoming Division of Disability and Elder Services Memos – Nursing Homes, Intermediate Care Facilities for Persons with Mental Retardation and Hospitals

Please visit the DDES Memos page at http://dhfs.wisconsin.gov/dsl_info/ index.htm for the link for the following upcoming Numbered Memos:

1. Revised Preadmission Screening and Resident Review (PASARR) Level I form (DDE-2191).
2. Revision of the DSL-822 form (approval from the county to admit a person who has a mental illness or developmental disability to a nursing home or an ICF/MR) and relabeled the form as DDE-822.
3. Preadmission Screening and Resident Review (PASARR) Memorandum #9. This numbered memo updates and replaces the DSL – INFO Memos #96-01 dated January 1, 1996, #96-11 dated January 2, 1997, #97-13 dated July 1, 1997, and #97-14 dated August 28, 1997. These memos detailed the Wisconsin policies and procedures for implementing the federal PASARR requirements, the contact information for the PASARR contract agency and list of the County PASARR Liaisons. This memo does not detail any changes in policies or procedures, however, this memo does provide addition information related to other nursing home admission requirements.

4. Preadmission Screening and Resident Review (PASARR) Memorandum #10. This numbered memo details changes in Wisconsin's interpretation of the federal PASARR regulations regarding "specialized services" and "services of a lesser intensity" for persons who have a mental illness. For persons who have a developmental disability, there is no change in interpretation or policy regarding specialized services.

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New Resident Care Review Section Region Boundaries

In addition to the new Assisted Living Section regions described in the July 2004 BQA Quarterly Information Update, the Bureau of Quality Assurance (BQA) has created new region boundaries for the Resident Care Review Section (RCRS). This change will better redistribute survey staff responsibilities for nursing homes and intermediate care facilities for persons with mental retardation.

The new region maps can be seen on the BQA provider site at http://dhfs.wisconsin.gov/rl_DSL/Contacts/reglmap.htm and on the BQA Consumer information site at http://dhfs.wisconsin.gov/bqaconsumer/reglmap.htm.

The RCRS regions roughly correspond with the current Department regions, with the differences being:

• Douglas and Rusk counties in the DHFS Western region are now assigned to the RCRS Northern region.
• Juneau and Adams County in the DHFS Southern Region are now assigned to the RCRS Northern region.

These changes took place as of August 1^st, 2004.

Reminder Regarding Resident Choice

The Bureau has recently received some calls regarding residents’ right to choose their health care providers, for example, a dentist or occupational or physical therapist.

Some assisted living providers have given their residents letters informing them that a specific service, such as outpatient physical therapy, was available to the resident from a specific provider. Although these letters were not written with the intent of exclusivity, the readers were given the impression that the listed provider was the only provider available for use.

The Bureau would like to remind providers that through state statute and administrative rules BQA-regulated facilities are required to allow residents to use the licensed, certified or registered provider of health care and pharmacist of their choice. To facilitate resident choice facilities could provide residents with a listing of all of the home health or rehabilitation facilities in the area.

Although the regulations allow residents of Wisconsin nursing homes the freedom to choose a pharmacy provider, nursing home regulations place the responsibility for accurately administering medications on the nursing homes. With that responsibility goes the right to define certain uniform standards for drug distribution. The Bureau of Quality Assurance believes the information presented in BQA memo 97-021, available at http://dhfs.wisconsin.gov/rl_DSL/Publications/pdfmemos/97021.pdf (PDF 28 KB), is a fair balance between the resident’s right to choose a pharmacy provider and the nursing home’s need to provide an accurate system of drug distribution. Currently, Doug Englebert, BQA’s pharmacy consultant, is recommending that assisted living providers use the applicable guidance in BQA memo 97-021 until a more comprehensive assisted living memo can be developed with input from all affected parties.

If you have any questions regarding the above information, please contact the BQA Regional office staff for your area.

Influenza and Pneumococcal Vaccinations

Influenza and Pneumonia are vaccine preventable diseases and yet, combined they are the fifth leading cause of death in the U.S. for patients / residents aged 65 years and older. According to the most current (1999) U.S. Centers for Disease Control and Prevention National Nursing Home Survey, immunization rates for influenza (66%) and pneumonia (38%) are well below the Healthy People 2010 goal of 90 percent. Healthy People 2010 is a comprehensive, nationwide health promotion and disease prevention agenda developed by the Department of Health and Human Services. It contains 467 objectives designed to serve as a roadmap for improving the health of all people in the United States.

On October 2, 2002, the Centers for Medicare and Medicaid Services published a final rule which removed the requirement for a physician to order influenza and pneumococcal immunizations in Medicare and Medicaid participating hospitals, long-term care facilities, and home health agencies. This rule change was designed to increase adult immunization, decrease vaccine-preventable diseases and death, simplify the immunization process and increase adult immunization rates by allowing standing orders programs. Despite these efforts, adult immunization rates in nursing homes continue to be below the Healthy People 2010 goal of 90 percent based on review of OSCAR data collected during surveys. With the advent of the flu and pneumonia season, the Bureau of Quality Assurance recommends that all health care providers ensure that all patients / residents as well as staff are immunized against these vaccine preventable diseases.

The Centers for Disease Control and Prevention (CDC), the National Foundation for Infectious Diseases (NFID) and the Association for Professionals in Infection Control and Epidemiology (APIC) recommends all health care workers receive an annual influenza immunization. Research has indicated that health care workers infected with influenza can spread the virus to people in their care leading to institutional outbreaks.

On October 15, 2004, the Department of Health and Family Services issued an Emergency Order limiting the administration of influenza vaccine to individuals who meet the high priority criteria (http://dhfs.wisconsin.gov/communicable/influenza/pdf_files/ EmergOrder101504.pdf) [link no longer operable]. This Emergency Order was in direct response to a News Release from the United States Department of Health & Human Services announcing a shortage in the available influenza vaccine (www.hhs.gov/news/press/2004pres/20041005.html (exit DHFS). Providers are encouraged to work with individual patient / resident physicians and their regular vaccine supplier, as well as their local health department, to ensure individuals who are members of the high priority groups (patients/residents AND staff) are immunized.

For more information about influenza and pneumonia programs, please see BQA's website http://dhfs.wisconsin.gov/rl_DSL/Providers/ influenza.htm. Vicky Griffin, Nurse Consultant, is the primary contact person for influenza vaccine issues. She may be reached at 414-227-4705.

Further Internet sites of interest:

• Association for Professionals in Infection Control and Epidemiology: www.apic.org (exit DHFS)
• National Foundation for Infectious Diseases: www.nfid.org (exit DHFS)
• U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: www.cdc.gov (exit DHFS)

Critical Access Hospitals (CAHs)

The Centers for Medicare and Medicaid Services (CMS) has clarified what constitutes a critical access hospital (CAH) observation bed, where they may be located, and how they count against the statutory limit of 25 acute care inpatient beds. CMS’s interpretation of observation beds is based on the definition of CAH in Section 1820 (c) (B)(iii) of the Social Security Act. The Act defines a CAH as a facility that: "provides not more than 25 acute care inpatient beds…" A CAH may not have more than 25 hospital-type beds set up and capable of being used on the premises. Those hospitals having 25 beds plus four additional observation beds noted on their certificate of approval (COA) will be issued a new COA indicating that the CAH has only 25 licensed beds. CMS’s interpretation further specifies a length of stay limit of 48 hours for observation patients.

A CAH may use any of its beds for observation purposes. A hospital may also use observation beds that are not typical hospital-type beds and are not counted in the 25-bed maximum. Examples of beds not counted include gurneys, cots, recliner chairs or other types of beds that are not capable of being used for inpatient care.

In recognition of the CMS interpretation and definition of an observation bed and pursuant to HFS 124.04 (3)(b), the Department hereby grants a statewide waiver of HFS 124.40(2)(c) which restricted CAHs to four permanently placed 24 hour observation beds. With this waiver, the restriction on number, location and length of stay for observation beds is removed from the state requirement. No amended language addressing observation beds is planned.

Refer to the Administrative Rules Update article on "2003 Omnibus Rule Update". Check this new publication of HFS 124 for Administrative Rule Update effective Nov 1, 2004. It includes the amendment of HFS 124.40(2)(a) which changed the CAH bed limit from 15 acute plus a possible 10 additional swing beds to the total of 25 beds.

In accordance with the Medicare Modernization Act (MMA) Section 405 (g), Distinct Part Units (DPUs) of up to ten beds each used exclusively for inpatient rehabilitation and/or psychiatric services are permitted as of October 1, 2004. In recognition of MMA and pursuant to HFS 124.04(3)(b), the Department hereby grants a statewide waiver of HFS124.40(2)(a) and (b) which restrict CAHs to a total of 25 acute care/swing beds. With this waiver, DPUs will be recognized and licensed in addition to the 25-bed CAH acute care/swing beds.

These DPUs may qualify as Prospective Payment System-Exclusion (PPS-E) units.The Bureau of Quality Assurance (BQA) will conduct separate unannounced surveys for new PPS Exclusion units (first time) and for a small sample of existing distinct part units.

BQA will re-issue updated CAH Certificates of Approval (COA) based on the information CAHs submit to BQA on the DDE-2445 Hospital Annual Report. This annual report form was sent to all hospitals on August 2, 2004 and due back to BQA on/before October 1, 2004. The COA will specify:

• Total # of acute care/swing beds (maximum of 25 beds)
• Swing bed status, if applicable (yes or no)
• Rehabilitation DPU status, if applicable (maximum of 10 beds)
• Psychiatric DPU status, if applicable (maximum of 10 beds)

Observation beds will not be specified on the COA.

Latest CMS Survey & Certification Letters

Below is a list of Survey and Certification (S&C) Letters distributed by the federal Centers for Medicare and Medicaid Services (CMS) during the last quarter. These letters are posted as PDF files to the Internet via www.cms.gov/medicaid/survey-cert/letters.asp [link not operable at this time].

We have decided to omit listing letters that pertain only to state agency operations. All S&C Letters can be viewed at the Internet site. If you have questions about individual letters, contact Susan Hespen of BQA at (608) 266-0582 or e-mail hespesj@dhfs.state.wi.us.

Life Safety Code Clarification of Corridor Width

The Centers for Medicare and Medicaid Services (CMS) has issued a Survey & Certification letter 04-41 providing their policy regarding corridor width requirements when introducing computer touch screens in health care facilities. CMS has received several inquiries concerning the acceptability of corridor-mounted touch screens and questions whether or not the touch screen installation interferes with requirements for corridor width in a health care facility. You may view the letter online at www.cms.hhs.gov/medicaid/survey-cert/sc0441.pdf (exit DHFS; PDF 58 KB).

Physician Rubber-Stamped Signatures in Home Health Agencies and Hospices

The Centers for Medicare and Medicaid Services (CMS) S & C letter 04-35 (exit DHFS; PDF 64 KB), dated July 8, 2004 has the following provisions:

• "Home health agencies (HHAs) and hospices may accept a physician's rubber stamp signature for their clinical record documentation if this is permitted by Federal, state, and local law and authorized by the HHA's and hospice's policy.
• An HHA or hospice that accepts a physician's rubber stamp signature must obtain a signed statement from the physician attesting that he/she is the only one who has the stamp and uses it."

Wisconsin Home Health and Hospice administrative rules (HFS 133 and HFS 131 respectively) do not prohibit the use of a physician's rubber stamped signature. The rules requiring a physician signature do not restrict the form of that signature.

Therefore, for home health and hospice survey purposes, surveyors will not cite an agency for accepting a physician's rubber stamp signature for their clinical record documentation providing the agency has on file a written attestation from the physician that the stamp is for his/her sole use. The use of the rubber stamp also must be authorized by entity policy.

In January/February 2002, the Wisconsin Pharmacy Examining Board and the Wisconsin Medical Examining Board issued a joint statement basically stating that physician rubber stamp signatures cannot be used for prescription purposes. Pharmacies will not accept them. This, however, is between the pharmacy and the physician. It is not in the purview of home health and hospice surveyors.

Please feel free to contact Marianne Missfeldt at missfml@dhfs.state.wi.us if you have additional questions.

Upcoming Training

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

OASIS (Outcome and Assessment Information Set) Information

OASIS Resources

New Resources are available to assist HHAs with accurate and consistent coding of OASIS data items.

• CMS has revised a series of 384 OASIS questions and answers (Q&As). These Q&As are posted at www.QTSO.com/hhadownload.html (exit DHFS) (scroll to bottom of Internet site).

• Additional CMS Q&As from a letter to the OASIS Certificate and Competency Board (August 12, 2004). Obtain these Q&As in Bulletins on the State OASIS System Welcome Page, under CMS Q&As to OCCB.

• A special edition of CMS’ Medlearn Matters presents an overview of Medicare information resources available for researching inpatient discharges within 14 days of a HH admission. You can obtain this article at www.cms.hhs.gov/medlearn/matters/ mmarticles/2004/SE0410.pdf (exit DHFS).

Based on the current advances in wound care research, CMS will follow the recently issued opinion of the National Pressure Ulcer Advisory Panel (exit DHFS) (NPUAP) regarding healing status of Stage 1 and Stage 2 pressure ulcers for accurate coding of OASIS wound items by home health agencies.

"It is the opinion of the NPUAP that stage 1 pressure ulcers that heal to normal appearing skin are not at increased risk for future ulcer development. Similarly, NPUAP believes that Stage 2 pressure ulcers generally heal to nearly normal skin, but may result in some scar tissue formation. It is our opinion that healed stage 2 ulcers only minimally increase the future risk of pressure ulcers at that location, and do not result in the same increased risk of future ulcerations as does a healed stage 3 or stage 4 pressure ulcer where the underlying skin architecture is dramatically and permanently altered." NPUAP, June 30, 2004.

This opinion statement means that prior guidance on healed pressure ulcers to not "reverse stage" a Stage 1 or Stage 2 pressure ulcer no longer applies. Instead, clinicians and agencies should follow the new guidance identified below.

During the SOC or subsequent comprehensive assessments of the patient, if it is found that a patient has a healed Stage 1 or 2 pressure ulcer, the responses for OASIS data items are as follows:

(M0440) Does this patient have a Skin Lesion or Open Wound?

• If the patient has a healed Stage 1 pressure ulcer (and no other pressure ulcers OR skin lesions/wounds), the response would be ‘No’.
• If the patient has a healed Stage 2 pressure ulcer (and no other pressure ulcers OR skin lesions/wounds), the response may be either ‘No’ or ‘Yes’ depending on the clinician’s physical assessment of the healed wound site.
• If the patient has no scar tissue formation from the healed Stage 2 pressure ulcer, the accurate response is ‘No’.
• If the patient has some residual scar tissue formation, the response is ‘Yes’.

(M0445) Does this patient have a Pressure Ulcer?

• If the patient has a healed Stage 1 or 2 pressure ulcer (and no other pressure ulcers), the accurate response is ‘No’, following the skip pattern as indicated.

Reverse staging during the healing process is still not appropriate, i.e., a stage 2 pressure ulcer does not become a stage 1 pressure ulcer; it remains a stage 2 pressure ulcer until it is healed. Documentation in the clinical record will show healing.

NOTE: For accurate coding responses for healed Stage 3 and healed Stage 4 pressure ulcers, the guidance remains unchanged as noted in the OASIS Implementation Manual under the assessment strategies for (M0450) Current Number of Pressure Ulcers. Since the underlying skin architecture of a healed stage 3 or stage 4 pressure ulcer is dramatically and permanently altered, there is increased risk of future ulcerations. Therefore, the correct responses for documenting a healed Stage 3 or 4 pressure ulcer on the OASIS assessment is:

• M440 = 1, ‘Yes’, patient has a skin lesion
• M0445 = 1 ‘Yes’, patient has a pressure ulcer
• M0450 and 460 = appropriate stage when ulcer was deepest
• M0464 = 1, fully granulated (currently best response)

This policy guidance for accurate coding of these items was effective September 1, 2004. You can also obtain this guidance on the State OASIS System Welcome Page, under Bulletins or at: www.cms.hhs.gov/oasis/hhnew.asp (exit DHFS).

The OASIS Certificate and Competency Board, Inc. (OCCB) is a non-profit organization dedicated to promoting greater reliability in OASIS data through consistent application of guidelines provided by the Centers for Medicare and Medicaid Services (CMS).

The OCCB will facilitate this goal by offering a voluntary certificate examination which home care providers may take to demonstrate their expertise and commitment to OASIS data accuracy. Candidates who successfully complete the examination will be awarded the Certificate OASIS Specialist – Clinical (COS-C) designation.

You can obtain information on this organization at www.oasiscertificate.org (exit DHFS).

Effective October 1, 2004, home health agencies (HHAs) need only complete a Resumption of Care (RFA 3) assessment for their Medicare PPS patients if there is a Significant Change in Condition (SCIC) with intervening hospital stay and return home during the last 5 days of an episode (days 56-60). You can find this policy and the requirements for completing M0825 at section 4 in the table, "OASIS Considerations for Medicare PPS Patients, revised June 2004". You can obtain this table at either:

• The State OASIS System Welcome Page, under Bulletins, or
• The CMS website at: www.cms.hhs.gov/oasis/hhnew.asp (exit DHFS)

OASIS affects all Medicare-certified home health agencies (HHAs). OASIS data items are used for calculating your Outcome-Based Quality Monitoring (OBQM) Reports, Outcome-Based Quality Improvement (OBQI) Reports, Case Mix Profile, and PPS payment. The data is also used for the enhanced survey protocol and Home Health Compare. Knowing that, you want to make sure you understand how to code the data items and how to read and interpret your quality reports.

To help home health providers improve their understanding of OASIS, the Bureau of Quality Assurance (BQA) is planning the following OASIS related workshops:

Learn about the OASIS Quality Reports while sitting in your office. A two-part audio-conference training on reading and interpreting OASIS quality reports, originally scheduled for October, is now planned for later this year. The first part of the mini-series will discuss the Outcome-Based Quality Monitoring (OBQM) Report and the Case Mix Report. The second conference will discuss the Outcome-Based Quality Improvement (OBQI) Report. The programs are intended for new HHAs and staff.

Approximately six weeks prior to the events, brochures describing the teleconference will be posted under Bulletins on the State OASIS System Welcome Page and also mailed to all HHAs.

Administrative Rules Update

The legislative committees have completed their review of the proposed rules for chapters HFS 132 and 134, relating to sundry changes to the administrative rules for nursing homes and intermediate care facilities for persons with mental retardation. The Department filed the final order with the Secretary of State and the Revisor of Statutes on September 10, 2004 and anticipates the rule will become effective on November 1, 2004.

A copy of the full text of the rule and the full text of the fiscal estimate, and other documents associated with this rulemaking order may be obtained, at no charge, from the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov (exit DHFS). At this website, you can also register to receive email 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.

HFS 148 – "Cancer Drug Repository Program"

BQA is working 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. The proposed rules will be the 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 (exit DHFS).

The legislative committees have completed their review of the proposed rules for the Department’s 2003 "Omnibus Rule Making Order" that includes relatively minor revisions to the following BQA health-facility related rules: HFS 13, HFS 83, HFS 124, HFS 131, HFS 132, and HFS 134. The Department filed the final order with the Secretary of State and the Revisor of Statutes on September 14, 2004 and anticipates the rule will become effective on November 1, 2004. A copy of the hearing notice, a full text of the rule, the full text of the fiscal estimate, and other documents associated with this rulemaking order may be obtained, at no charge, from the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov (exit DHFS).

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]

Data Accuracy - Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Training Initiatives

The Centers for Medicare and Medicaid Services (CMS) has contracted with Computer Sciences Corporation (CSC) to assess the accuracy and reliability of assessment data submitted by long-term care and skilled nursing facilities. This project is referred to as the Data Assessment and Verification (DAVE) project. The DAVE project supports CMS’ efforts to establish a standardized process for measuring and improving the accuracy and reliability of provider submitted MDS assessment data. The DAVE project supports improvements in quality of care, CMS’ program integrity initiatives to improve payment accuracy, and payment policy development. Under this contract CSC will conduct audits of MDS assessments, claims, and supporting documentation for long-term care and skilled nursing facilities that are participating in the Medicare and/or Medicaid programs. Along with this effort the DAVE project is developing coordinated and directed approaches to national provider educational activities.

The first of three-planned multimedia broadcasts about MDS coding and data accuracy was conducted on August 27, 2004. This 2-hour program focused on coding Section G- Physical Functioning and Structural Problem; and Section P, Item 3- Nursing Rehabilitation/restorative care. If you were unable to participate in the live broadcast you can view this program at the following Internet site http://cms.internetstreaming.com (exit DHFS). This program will be available for one year. The next live broadcast is scheduled for Friday, October 29, 2004; this program will focus on MDS sections: J - Health Conditions, I - Disease Diagnosis, and O - Medications. For program details and handout materials connect with the Internet-streaming website noted above.

As part of the DAVE project’s educational outreach a course was developed based on the results pre-national analytic findings. The course contains PowerPoint presentation and supporting course materials that focus on the top five discrepant items in Sections G, I, J, O, and P of the MDS 2.0 Assessment. This PowerPoint presentation is available to providers in the "Bulletins" section of the State’s MDS automated system. To view this 105-slide PowerPoint presentation, you will need to have PowerPoint software on your computer.

The Bureau of Quality Assurance continues its efforts to provide ongoing statewide provider training programs on the use of the Resident Assessment Instrument (RAI), accurately coding the MDS and the MDS automation process. Current RAI and MDS programs reflect analytical findings of the DAVE project.

For more information check these CMS websites:

• DAVE Home Page: www.cms.hhs.gov/providers/psc/dave/ homepage.asp (exit DHFS) [site removed, replacement info]
• MDS 2.0 Information Site: www.cms.hhs.gov/medicaid/mds20 (exit DHFS)
• Open Door Initiative: www.cms.hhs.gov/opendoor (exit DHFS)

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