DQA Quarterly Information Update

April 2009

PDF Version of this month's Quarterly Update (PDF, 110 KB)

NEW THIS ISSUE

• NERO Moves
• Bureau of Assisted Living Restructuring
• DQA Focus 2009 Conference
• DHS 35 New Outpatient Mental Health Clinic Rule
• Basic Home Health Online Course
• Dementia and Antipsychotics
• Nurse Aide Registry Transfers
• Wireless Handheld Device Usage
• MDS 3.0 Delayed
• Revisions to the RAI Manual 2.0
• Home Health OASIS-C:  History and Update

REGULAR FEATURE

• Changes in DQA Staff
• DQA Numbered Memos
• Administrative Rules Update
• Latest CMS Survey & Certification Letters

UPCOMING EVENTS

• DQA Focus 2009 Conference ....... October 21 - 22

NEW THIS ISSUE

NERO Moves

On March 19, 2009, the DQA Northeastern Regional Office moved from its location in Green Bay to a new location in De Pere. As of that date, all correspondence should be directed to the De Pere address. Additionally, staff telephone numbers have changed. DQA memo 09-009 contains updated NERO contact information.

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Bureau of Assisted Living Restructuring

Effective April 1, 2009, the Bureau of Assisted Living ceased operations in the Northern Regional Office located in Rhinelander. Facilities previously assigned to the Northern Regional Office have been reassigned to the Western Regional Office in Eau Claire, the Northeastern Regional Office in De Pere, and the Southern Regional Office in Madison. DQA memo 09-011 contains links to the new regional maps, surveyor regional assignments and updated telephone numbers.

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DQA Focus 2009 Conference

The Wisconsin Department of Health Services, Division of Quality Assurance, is pleased to announce the 9th annual conference for health care providers and DQA staff on October 22, 2009, at the Kalahari Convention Center in Wisconsin Dells. The Focus 2009 conference is being developed in collaboration with health care providers and associations and is designed to bring a best-in-the-industry lineup of presenters to challenge and improve your day-to-day work.

Focus 2009, "Furthering Our Commitment to Ultimate Service," will provide an exceptional lineup of presentations. The conference will feature two keynote speakers. Dr. Gregory Poland will kick off the conference with a presentation entitled "Influenza Immunization of Health Care Workers." Dr. Poland is a national and international expert in the field of vaccinology and clinical research and is the director of Mayo Clinic's Vaccine Research Group. In the afternoon, the keynote speaker will be Clint Maun. Clint is a nationally recognized leader in healthcare consulting, speaking, and research.

On October 21, 2009, prior to Focus 2009, DQA will offer two special sessions: "The Art and Science of Pressure Ulcer Prevention and Treatment" and "The ServSafe Training." The "Art and Science of Pressure Ulcer Prevention and Treatment" will feature pressure ulcer expert Joyce Black, Ph.D., former president of the National Pressure Ulcer Advisory Panel.

"The ServSafe Training" will be taught by Certified ServSafe Instructor, Rich Daehn. The ServSafe Training will provide participants with the knowledge, skills, and abilities needed to set high food safety standards. Upon completion of the ServSafe course, participants will be given the opportunity to take an approved exam to become a Certified Dietary Manager.

We are excited about this year's conference. Please save the dates!

More information will be included on our conference website as plans are finalized. Please visit: http://dhs.wisconsin.gov/rl_dsl/training/focus09.htm

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DHS 35 New Outpatient Mental Health Clinic Rule

The new DHS 35 will likely be published sometime in May 2009 with an anticipated effective date of June 1, 2009. The Division of Mental Health and Substance Abuse Services and the Division of Quality Assurance issued a joint memo announcing training events for the new rule. Refer to joint DQA/DMHSAS memo 09-008 for additional information at:
http://dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm

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REMINDER!! Basic Home Health Online Course

The Basic Home Health Online Course is an educational course that provides individuals that take the training with the opportunity to learn the basic federal home health regulations. This interactive course is intended to build a foundation of understanding about the home health agency federal regulations. The federal home health agency Conditions of Participation (CoPs) and Appendix B of the State Operations Manual (SOM) are the basis for this course. Appendix B includes the regulations, interpretative guidelines, and questions to consider when determining if home health agencies are following federal regulations.

Many home health agency staff have already taken the course and provided very positive feedback.

The cost to take the course is $25.00 per person. The course is available 24/7 via the Internet. Additional information is included in the course description located on the registration website.

Register online at: https://wisccharge.wisc.edu/quality/current_courses.asp

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Medication Black Box Warnings: What Nursing Homes Need to Know

Each day more information becomes available regarding the use of antipsychotic medications for elderly individuals with dementia. Since 2005, a black box warning has existed for the newer generation of antipsychotics. Recently the older antipsychotic medications have also been given the same black box warning. For antipsychotics, the black box warning is a high level precaution warning prescribers that the use of antipsychotic medications in elderly individuals with dementia, or related illnesses, can cause death.

The Division of Quality Assurance (DQA) has previously addressed the use of antipsychotic medications that are prescribed to elderly residents with dementia. Please review the links to previously issued pharmacy newsletters on this subject. Federally certified nursing homes are also encouraged to review the Medicare State Operations Manual and the guidance specific to the use of antipsychotic medications.

Please remember that when antipsychotic medications are used for nursing home resident behaviors that are not associated with a mental illness there are multiple conditions that must be met to avoid the risk of a deficient practice citation. Due to the black box warning and the nature of the medication, facilities should be developing plans of care specific to the antipsychotic medication that include monitoring for the medication's effectiveness and side effects.

http://dhs.wisconsin.gov/rl_DSL/Publications/pharMayJun03.pdf

http://dhs.wisconsin.gov/rl_DSL/Publications/pharmJulAugSep05.pdf

http://dhs.wisconsin.gov/rl_DSL/Publications/PharmNovDec08.pd 

Existing regulations have not changed with federal Food and Drug Administration advisories issued in previous years regarding black box warnings. Facilities must discuss with residents, families, legal representatives, the consultant pharmacist, medical director, and physicians the use of these medications, including a thorough discussion of the risks, benefits, and potential side effects before starting or making any changes with antipsychotic therapy. 

This is especially important when antipsychotic medications are used for behaviors related to Alzheimer's Disease, dementia or other organic brain disorders. While written informed consent is not mandatory for the use of antipsychotic medication to treat dementia-related behaviors, it has become a common practice for nursing homes to document this type of consent. We encourage nursing homes to continue this process. 

The Department has made available a form used in facilities operated by the Department, but accessible to the public. Please access the Department's website at http://dhs.wisconsin.gov/forms1/F2/MedBrandName.htm for an updated version of the form. If, however, a nursing home chooses to implement its own form, care must be given to ensuring that the document contains sufficient information needed for a proper informed consent to be granted. Please continue to check the above website for any updates made to this form.

Facilities need to have information which supports that the facility has considered all the standards related to antipsychotic medication use in behaviors that are the result of Alzheimer's Disease, dementia, or other organic brain disorders. When antipsychotic medications are being used for behavior treatment, a specific monitoring program that looks at effectiveness and side effects, must be in place. 

Monitoring includes appropriately training direct care staff on recognizing the signs and symptoms that may appear due to a resident taking these medications. This is important in determining the drug's effectiveness, or lack thereof. Continuous communication between nursing staff and the facility's medical director and pharmacy consultant is, therefore, critical to ongoing monitoring within the facility.

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Nurse Aide Registry Transfers

An individual may apply to transfer from one state's nurse aide registry to another state's nurse aide registry. However, the person should always contact the state registry that they wish to transfer to in order to learn what that state's eligibility requirements are for placement on that registry. Although all states must comply with the federal requirements, each state established its own rules regarding the management of their individual registry.

An individual wishing to transfer their nurse aide status to the Wisconsin Nurse Aide Registry must satisfy all of the following:

• Satisfactory completion of a nurse aide training program of at least 120 hours, of which 32 of those hours were in a clinical setting.
• After completion of the training program, satisfactory completion of a comprehensive nurse aide competency examination, which included both written and skills.
• Eligibility to work in federally-certified nursing homes and Intermediate Care Facilities for persons with Mental Retardation (ICF/MRs).

The names of individuals who meet these requirements will be placed on the Wisconsin Nurse Aide Registry.

Individuals who do not meet the above requirements may become eligible for placement on the Wisconsin Nurse Aide Registry by satisfying one of the following:

• An individual, who is listed on another state's registry but has not completed a nurse aide training program of 120 hours, must successfully complete both a 120 hour nurse aide training program and a comprehensive competency exam (including both written and skills components).
• An individual, who is listed on another state's registry and who has completed a nurse aide training program of at least 120 hours but did not take a comprehensive competency examination, will be required to successfully complete the Wisconsin competency examination.
• An individual, who is listed on another state's registry, has completed a nurse aide training program of at least 120 hours and a comprehensive competency examination but their eligibility to work in a federally-certified healthcare setting has expired, will be required to successfully complete the Wisconsin competency examination.
• An individual, who is not listed on another state's registry but has completed an approved nurse aide training program of at least 120 hours in that state within the last year but has not taken a comprehensive competency examination, will be required to successfully complete the Wisconsin competency examination.

A nurse aide wishing to transfer to the Wisconsin Nurse Aide Registry must complete and submit a Nurse Aide Registry Out-of-State Application.

• Individuals transferring from California, Colorado, Illinois, Missouri, North and South Carolina should send the application to:

Office of Caregiver Quality
P.O. Box 2969
Madison, WI 53701

• All other nurse aides should mail the out-of-state application to the state registry that they are currently listed on.

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Wireless Handheld Device Usage

As the popularity of wireless handheld devices and social networking websites increases, so does the potential for misuse or abuse by electronic means. The Office of Caregiver Quality is currently drafting a memo to provide facilities with some guidance regarding the use of wireless devices such as cell phones, cameras, personal digital assistants (PDAs) and laptops.

OCQ has seen an increase in the number of caregiver misconduct complaints regarding the misuse of these devices and encourages all entities to be proactive in protecting their clients by adopting written policies that define appropriate and inappropriate use. If your facility has adopted policies or procedures addressing these issues and would like to share examples, please contact OCQ at the number or e-mail address below.

Questions?  Contact the DQA Office of Caregiver Quality at:
(608) 261-8319 Telephone
(608) 264-6340 FAX
DHSCaregiverIntake@dhs.wisconsin.gov

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MDS 3.0 Delayed

CMS has revised the implementation date for MDS 3.0 to October 1, 2010. CMS has stated that in October of 2009, a finalized version of the revised data specifications, RAI Manual version 3.0, and MDS 3.0 forms will be published. We are hopeful that this extended roll out will give all stakeholders time for a comprehensive and smooth transition to a new and improved assessment tool.

Nursing homes are encouraged to participate in CMS Skilled Nursing Facilities/Long Term Care Open Door Forums to stay updated on the MDS and related issues of significance for nursing facilities. Facilities may sign up to receive e-mail notification of Open Door Forums at the following website: http://www.cms.hhs.gov/OpenDoorForums/25_ODF_SNFLTC.asp

Revisions to the RAI Manual 2.0

The December 2008 revisions to the RAI Manual 2.0 are available on the CMS MDS 2.0 website. Updates can be viewed and downloaded at:
http://www.cms.hhs.gov/nursinghomequalityinits/20_nhqimds20.asp

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Home Health OASIS-C: History and Update

Development of the next major revision of OASIS, termed "OASIS-C," began in 2005. Field-testing was completed in 2008. The Centers for Medicare and Medicaid Services (CMS) has advanced through several drafts of OASIS-C and remains on task for a final version to become effective January 1, 2010. CMS held a public comment period, which ended January 13, 2009, and has completed its review and response to the public comments, resulting in 'version 12.2' of OASIS-C.

An earlier draft of OASIS-C was originally posted to CMS's 'Paperwork Reduction Act of 1995' website. Version 12.2 is now posted to CMS's 'Home Health Quality Initiative' website, located at: http://www.cms.hhs.gov/HomeHealthQualityInits/. Once on this website, select 'OASIS-C' from the left-hand column. Then, scroll to the bottom of the web-page to view OASIS-C version 12.2, CMS's response to public commentary, and the March 9, 2009 Federal Register notice of CMS's request for OMB approval to modify the OASIS data set.

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REGULAR FEATURES

Changes in DQA Staff

Bureau of Assisted Living - SRO

Ms. Emily Schmitt joined the Southern Regional office as a License/Permit Program Associate in the Bureau of Assisted Living on 1/20/2009. Emily is a very recent graduate of the University Wisconsin - Madison in Sociology and Social Welfare. While at the University, she was employed by the UW Office of Student Financial Services as an Information Specialist and Imaging Specialist. Emily volunteered with HospiceCare and The Salvation Army and served on a number of committees while attending the university.

Bureau of Assisted Living - SERO

Renee Polley joined the Southeastern Regional office as a License/Permit Program Associate in the Bureau of Assisted Living on 3/2/2009. Renee is a graduate of Mount Mary College and has completed graduate level courses in management and Information Technology. Renee transferred from the University of Wisconsin - Whitewater where she provided administrative support. Renee brings a wide variety of experiences and talents to her position in the Bureau of Assisted Living.

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DQA Numbered Memos (January, February, March)

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

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HFS Administrative Rules Update

DHS 12 - Caregiver Background Checks

On September 15, 2008, the Wisconsin Administrative Rules website published the Initial Proposed Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code, Chapter DHS 12. Section 50.065(2m)(d), Wis. Stats., requires the Department to promulgate rules to specify crimes for which an entity must disclose to a client or the client's guardian, a conviction of a caregiver who is assigned to provide personal care services to the client in the client's personal residence, and to specify who is a "substitute caregiver." The proposed rule was revised based upon comments received from advocacy organizations, trade and professional associations, and other interested parties.

On March 2, 2009, the Wisconsin Administrative Rules website published the Final Rulemaking Order including a summary and text of the proposed rule, Wisconsin Administrative Code Chapter DHS 12.

For more information, you may view the final rule order on the Wisconsin Administrative Rules website at: http://adminrules.wisconsin.gov/

DHS 83 - Community Based Residential Facilities

On April 1, 2009, revisions to Wisconsin Administrative Code, Chapter DHS 83 went into effect. The revised rule contains several changes that CBRF providers need to be aware of, including changes to the administrator qualifications, training requirements, medication administration requirements, and sprinkler system requirements for small class C facilities. The rule may be viewed at: http://www.legis.state.wi.us/rsb/code/dhs/dhs083.pdf

Staff from the Bureau of Assisted Living has developed industry training on the new requirements in DHS 83 for CBRF staff. The training is presented in four (4) modules and includes valuable handouts you can download that provide information on how the new rule will affect your facility. The training is web-based and available on the Wisconsin Department of Health Services website. You can access the training modules and handouts at: http://dhs.wisconsin.gov/rl_DSL/Training/dqaWebcasts.htm

Please watch for important memos related to the implementation of DHS 83. The link to the CBRF memos can be found at: http://dhs.wisconsin.gov/rl_DSL/CBRF/CBRFnodMemos.htm

DHS 85 - Non-Profit Corporation as Guardian

On September 19, 2006, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter DHS 85, Non-profit Corporation as Guardian. Through this initiative, the Department proposes to make the rule reflect current standards of practice, recognizing the increase in the number of adults in need of guardianship and the increase in the complexity of their needs.

An Advisory Committee, including advocates, providers, registers in probate, and County adult protective services staff, met and reviewed proposed rule language and made recommendations for change. The Department revised the proposed rule based upon comments from the Advisory Committee. The proposed Rule Order is currently under review by the DHS Office of Legal Counsel. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at: http://adminrules.wisconsin.gov/

DHS 124 - Hospitals

On April 1, 2005, the Wisconsin Administrative Register published a Statement of Scope of proposed rules to amend Chapter 124. The Department is planning to update Chapter DHS 124 to eliminate overly prescriptive and outdated regulations, clarify the Department's enforcement authority, and make the rule more consistent with the federal Medicare requirements.

The Department asked representatives from a large number of trade and professional associations, hospitals, and other interested parties, to review proposed revisions to the rule and make recommendations for change. The Department is reviewing their recommendations and preparing a revised draft of ch. DHS 124 for further review by stakeholders. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules website at: http://adminrules.wisconsin.gov/

DHS 129 - Certification Programs for Training and Testing Nurse Aides, Home Health Aides, and Hospice Aides

On December 1, 2008, revisions to Chapter DHS 129 went into effect. The revised rule includes training and testing requirements of feeding assistants and medications aides, reflects the standardization of the administration and operation of nurse aide competency evaluation by a contracted agency, improves the accuracy and integrity of the nurse aide registry, and expands the mechanisms available for enforcing compliance of training and testing programs. For more information, you may view the rule at: http://www.legis.state.wi.us/rsb/code/dhs/dhs129.pdf

DQA Memos 08-026 and 08-030 provide important information about the implementation of the revised rule and can be found at: http://dhs.wisconsin.gov/rl_DSL/Publications/BQAnodMems.htm

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CMS Survey & Certification Letters (January, February, March)

Listed below are Survey and Certification (S&C) Letters distributed by CMS during the last quarter. Please note that the CMS Internet site where you can review all S&C memos is:
http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp 

Content contact: Gina Bertolini
Phone: (608) 266-6691

E-MAIL SUBSCRIPTION SERVICES

http://dhs.wisconsin.gov/rl_DSL/Listserv/signup.HTM

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Last Updated: April 06, 2009