DQA Quarterly Information Update

April 2004

[Acrobat Version of this month's Quarterly Update (PDF, 258 KB) - blue text indicate links to other pages or Internet sites]

• Bureau of Quality Assurance 4^th ANNUAL PROVIDER CONFERENCE

• Susan Schroeder Leaving as Director of Bureau of Quality Assurance

• Dolores Zwiers Retiring as Regional Field Operations Director

• Communication with BQA Senior Management

• BQA Numbered Memos January – March 2004

• Rural Health Clinic Final Rule

• Recall of Patient Lifts

• Survey Guides

• Bureau Consultant in Webcast Presentation

• New Directories

• New Hospice and Facility Interface Guide

• Variance for Supervision Requirements for Mental Health Professionals

• Federal Information: Hospital Discounts for Uninsured Patients

• Upcoming Seminar/Training Opportunities – New Online Registration Available

• OASIS Online Reports Require a New Plug-In

• Reminder Regarding Home Health Agency Branch ID Numbers

• OASIS Submissions

• Elder Abuse Resource Information

• Latest CMS Survey & Certification Letters

• Procedures in Event of a Fire at Medicare- or Medicaid-Certified Health Care Facility

• Overnight Stays at Ambulatory Surgical Centers

• Health Insurance Portability and Accountability Act (HIPAA) and the Nursing Home Requirement for Posting Survey Results

• Administrative Rules Update

Bureau of Quality Assurance 4^th ANNUAL PROVIDER CONFERENCE

Don’t miss this one! We’re excited to announce this year’s Annual BQA Provider Conference will be held August 9^th, 2004. The conference "FOCUS 2004: COLLABORATING FOR QUALITY" will be held at the American Family National Headquarters Training Center located at 6000 American Parkway in Madison. Caregivers and management from assisted living facilities, nursing homes and intermediate care facilities for persons with mental retardation will benefit from the conference theme "Achieving Quality Through Standards of Practice."

The conference will feature a morning and afternoon keynote address, along with breakout sessions specific to assisted living and long term care issues. All breakout sessions and exhibits will provide practical and exciting information centered on the conference title and theme.

The conference includes:

• Morning Keynote – Building Bridges for Quality and Collaboration: The Journey of Caregiving
• Breakout Sessions - How to Meet Regulatory Compliance under the Wisconsin Caregiver Law; Continuous Quality Improvement Initiatives; Strategies to Engage Persons with Mental Illness; Diabetes Care; Restraint Reduction in Community Settings; Power of Attorney Information; Urinary Incontinence
• Afternoon Keynote – How to Investigate Abuse.

Brochures and registration information will be available the week of May 27^th, 2004. Remember to check the BQA web site at http://dhfs.wisconsin.gov/rl_dsl/training/index.htm for further information about this conference.

DEPARTURES

Susan Schroeder Leaving as Director of Bureau of Quality Assurance

Susan Schroeder, Director of the Bureau of Quality Assurance since 1999, will be departing the Bureau effective July 15, 2004. The Division of Disability and Elder Services has initiated recruitment efforts to fill the Director position Susan is vacating. We anticipate that a successor will be appointed before July 15^th. Announcements will be made in forthcoming Quarterly Updates.

In her five years with the Bureau, Ms. Schroeder has made many accomplishments, including the following:

• Wisconsin's nursing home technical assistance project concept became a national initiative and is producing real results improving care quality for consumers. The concept is also being applied to home health agencies and hospitals.

• Establishing the Assisted Living Section.

• Managing many nursing home closures, receiverships and resident relocations - often simultaneously. The outcomes for consumers have been good and when they were not, the Bureau has studied why and what can be done better the next time.

• Wisconsin's Caregiver Law and Feeding Assistant Program, implemented and sustained by the Bureau, became national models.

• Regulatory flexibility exercised by BQA made it possible for providers to bring new health care delivery systems and methodologies to Wisconsin citizens while protecting public health, safety and welfare. Mercy Hospital's Satellite Emergency Department in Walworth is an example among many.

• Many positive, productive, and correct working relationships were developed and improved with internal and external stakeholders such as the U.S. Centers for Medicare and Medicaid Services.

In addition to her work as Bureau Director, Susan also served as Secretary of the Association of Health Facility Survey Agencies, the organization representing the 50 state agencies that perform survey and other regulatory activities.

Dolores Zwiers Retiring as Regional Field Operations Director

The Bureau said farewell to a long-term dedicated public servant with the departure of Dolores Zwiers from the Northeastern Region Resident Care Review Section in Green Bay on March 31^st, 2004 after 30 years of state service. Before taking on the position as Regional Field Operations Director, Dolores served the Bureau as an Assistant to the Regional Field Operations Director, supervising the Office’s program assistants and then as a Regional Field Operations Supervisor responsible for survey staff.

Dolores’ tenure as Regional Field Operations Director coincided with a number of surveyor and supervisor vacancies in her section that remained unfilled for long periods, requiring Dolores to take on those responsibilities along with her own. Her competence and commitment to the consumers we serve allowed the Section to cope with the increased workload very well indeed.

Dolores’ professional experience and expertise have been much appreciated throughout the state, not just in the Bureau. We are sorry to see Dolores go, but wish her the best in her retirement.

While the search is being conducted to fill Dolores’ place, Joanne Powell will serve as interim Regional Field Operations Director. Joanne will be covering for both the Northern and the Northeastern Regions.

Susan and Dolores will be missed, not only by their colleagues in the Bureau and the Department, but by the provider community with whom they maintained effective, collegial working relationships; and by Wisconsin’s elderly and disabled citizens, for whom both worked for high quality delivery of long term care services in the state. Please join all of us in the Bureau in wishing both good luck in their future pursuits.

Communication with BQA Senior Management

To improve the timelines of communication with Bureau of Quality Assurance (BQA) senior management, the telephone number (608) 266-8481 has been designated as the number providers and the public can call to immediately, or within a short time, reach the member of the BQA management team who can resolve problems. This number will be highlighted in print communications and on BQA Internet pages.

Immediate response and resolution of your concerns is our goal. The number (608) 266-8481 will be available to receive calls on a 24-hour basis with voice mail set up to take messages when staff are not available to answer the phone. Should an individual not be immediately available to answer your call, voice-mail messages will be checked at least hourly during business hours (Monday through Friday 8:00-4:30), to ensure a timely response to your call/questions. Upon receipt of the call, the message will be transferred to the BQA manager whose section is responsible for the subject matter. The table on the next page lists the BQA managers and the programs over which they have authority to respond to questions, when received. If, however, your desire is to speak to the BQA Director or the Deputy Director, the table contains telephone numbers and email addresses at which you can contact them.

Again, our goal is to make BQA management immediately available to the public and to provider communities when issues have not been resolved through previous efforts. However, we continue to encourage communication to resolve problems with regional or mid level supervisors within BQA first.

BQA Numbered Memos January – March 2004

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:

• 95-023 – Nursing Home guidelines, newer procedures in place
• 92-066 – Medication Administration by Home Health and Personal Care Workers – replaced by memo 04-004 (above)
• 01-049, 01-033, 01-022, 00-066 and 93-024 were all replaced by 04-008 (above)

Rural Health Clinic Final Rule

The Centers for Medicare and Medicaid Services (CMS) Rural Health Clinic Final Rule was published in the Federal Register on December 24, 2003. A copy can be downloaded and printed from this web site: http://a257.g.akamaitech.net/7/257/2422/14mar20010800/ edocket.access.gpo.gov/2003/pdf/03-31572.pdf (exit DHFS, PDF). You can also search for this final rule via the Federal Register listings for this date at www.access.gpo.gov/su_docs/fedreg/a031224c.html (exit DHFS).

These final regulations amend Medicare certification requirements and implement provisions of the Balanced Budget Act of 1997. Changes include:

• Amended definition of qualifying rural shortage area where the rural health clinic must be located.
• Criteria established for rural health clinics essential to delivery of primary care services in areas that have been removed from designation as medically underserved areas (MUA).
• Limits set on staffing requirement waivers.
• Program evaluation replaced with a quality assessment and performance improvement program.
• Payment limits imposed prohibiting "commingling" (the use of the space, professional staff, equipment, and other resources of an RHC with another entity).

The regulations were effective February 23, 2004. If you have further questions about the Wisconsin Rural Health Clinic Survey process, you may contact Jean Kollasch, Provider Regulation & Quality Improvement Section, (608) 267-0466 or Jane Walters, Health Services Section, at (608) 266-7952 [replaced by Cremear Mims, (608) 243-2028].

Recall of Patient Lifts

The FDA recently notified healthcare professionals of a Class I recall of Faaborg battery operated patient lifts distributed by Moving Solutions, Inc., of Downers Grove, Ill., because of a faulty design. Excessive wear of the main bolt, which secures the lift arm to the main frame of the patient lift, will cause the bolt to break which will cause the patient to fall and could result in serious injury, even death. The FDA has received one report of a death related to the failure of the bolt. Facilities should stop using these lifts until the problem is corrected. You may access the full safety summary at www.fda.gov/medwatch/SAFETY/2004/ safety04.htm (exit DHFS).

Survey Guides

The Bureau of Quality Assurance has posted several guides to its survey processes in order to help providers, clients, families, advocates, and other interested parties understand what is involved when a provider is surveyed.

• Survey Guide, Assisted Living Facilities - http://dhfs.wisconsin.gov/rl_DSL/Providers/pde3186.pdf (PDF, 136 KB)

• Survey Guide, AODA / Mental Health Agency Certification - http://dhs.wisconsin.gov/publications/p6/p63174.pdf (PDF, 35 KB)

• Survey Guide, Facilities Serving People with Developmental Disabilities - http://dhfs.wisconsin.gov/rl_DSL/FDDs/pde3051.pdf (PDF, 45 KB)

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Bureau Consultant in Webcast Presentation

On November 21, 2003, Doug Englebert, Pharmacy Practice Consultant for the Bureau of Quality Assurance, participated in a Centers for Medicare and Medicaid Services (CMS) webcast "Basic Medication in an ICF/MR," addressing medication use in intermediate care facilities for the mentally retarded (ICFs/MR). While the broadcast focused on training state agency surveyors regarding pharmacy standards in these facilities, it contains material of interest to providers and consumers as well. The broadcast will be available for at least a year after the presentation.

If you are interested in viewing this presentation, visit the CMS broadcasting site at http://surveyortraining.cms.hhs.gov/ (exit DHFS).

New Directories

• Certified mental health and alcohol and other drug abuse treatment programs
• End-stage renal dialysis providers
• Outpatient rehabilitation facilities (including comprehensive outpatient rehabilitation)
• Portable X-ray services

We have also amended hospice and home health agency directories to include information about branch offices.

Providers are reminded to contact their appropriate licensing specialist or regional office if changes need to be made to directory entries. If you have further questions about provider directories, please e-mail Todd McCall at mccaltw@dhfs.state.wi.us or call (608) 267-3808.

New Hospice and Facility Interface Guide

By May 1, 2004, the Bureau of Quality Assurance will post a new "Hospice/Residential Care Apartment Complex Interface" guideline in conjunction with the Hospice Organization and Palliative Experts (HOPE) of Wisconsin. Go to the DHFS Licensing, Certification and Registration page at http://dhfs.wisconsin.gov/rl_DSL and select either "Hospice" or "Residential Care Apartment Complexes" and then "Providers" to see links to this guideline. This document joins the following items in providing guidance for coordinating hospice care in a variety of settings:

• Guidelines for Care Coordination for Hospice Patients Who Reside in Nursing Homes http://dhfs.wisconsin.gov/rl_DSL/ Publications/01042a.htm

• Hospice/CBRF Interface http://dhfs.wisconsin.gov/rl_dsl/Hospice/ HospiceCBRFguidelines.pdf (PDF, 174 KB)

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Variance for Supervision Requirements for Mental Health Professionals

The Variance for Supervision Requirements for Certified Outpatient Mental Health Clinics (BQA memo 04-005 at http://dhfs.wisconsin.gov/rl_DSL/Publications/04-005.htm) was published February 4, 2004. This variance permits "clinical collaboration" in certified outpatient mental health clinic settings in lieu of or in addition to M.D./Ph.D. supervision as required under HFS 61.97(3). This variance only applies to certified outpatient psychotherapy clinics.

Certified outpatient psychotherapy clinics must develop and implement a written policy for clinical collaboration for their licensed psychotherapy staff and determine a timeline for transition. Certified clinics must submit a written document to the BQA surveyor detailing their timeline for transition. The BQA surveyor will review the policy and confirm compliance during scheduled or unscheduled visits. Addresses and phone numbers can be found at this address http://dhfs.wisconsin.gov/rl_DSL/MentalHealth/BQApcuStaff.htm.

Federal Information: Hospital Discounts for Uninsured Patients

The following information was sent by Carol Plum, Centers for Medicare and Medicaid Services (CMS) in response to questions from hospitals regarding offering discounts to the uninsured.

• Questions and Answers on Charges to the Uninsured: www.cms.hhs.gov/FAQ_Uninsured.pdf [link no longer operable]

• Department of Health & Human Services Secretary Thompson's letter (news release): www.os.dhhs.gov/news/press/2004pres/20040219.html [link no longer operable]

• Department of Health & Human Services, Office of Inspector General Report: "Hospital Discounts Offered to Patients Who Cannot Afford to Pay Their Hospital Bills:" http://oig.hhs.gov/fraud/docs/alertsandbulletins/2004/ FA021904hospitaldiscounts.pdf ( exit DHFS, PDF)

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Upcoming Seminar/Training Opportunities – New Online Registration Available

We are pleased to announce the arrival of online registration, including the ability to pay using credit cards, for Bureau of Quality Assurance events. Check it out on the BQA Provider Training page at http://dhfs.wisconsin.gov/rl_DSL/Training/index.htm. The Bureau has contracted with UW DoIT services to set up and maintain this online registration site. We will continue to mail out brochures on upcoming training to providers, who will still have the option to fill them out and mail them back with checks. For registration questions, contact the Bureau of Quality Assurance Training Coordinator at (608) 267-1438.

OASIS Online Reports Require a New Plug-In

On March 28, 2004 CMS performed an upgrade to the Certification And Survey Performance Evaluation Reporting (CASPER) system that will require home health agencies (HHAs) to download a new plug-in file to view reports. The CASPER system allows HHAs to obtain Outcome-based Quality Monitoring reports (OBQM), Outcome-based Quality Improvement reports (OBQI), and additional online reports. HHAs that use Netscape as their Internet browser will need to follow the instructions on the CASPER login page to download the updated plug-in file. Internet Explorer users will be prompted to download the plug-in file the first time they attempt to view a report that was requested after the upgrade. Users only need to download this file one time.

Reminder Regarding Home Health Agency Branch ID Numbers

HHAs must enter the appropriate value in the OASIS Branch ID item M0016 for assessments completed on or after January 1, 2004. Failure to enter the correct information will result in the OASIS record being rejected by the State OASIS System. Rejected records must be corrected and resubmitted. The M0016 completion rules are as follows:

• If an HHA with no branches completes the OASIS assessment, M0016 must start with the letter N followed by 9 spaces.

• If a branch completes the OASIS assessment, M0016 must contain the 10-character ID that was provided to HHAs by the CMS Regional Office.

• If a parent HHA that has branch offices completes the OASIS assessment, M0016 must start with the letter P followed by 9 spaces.

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OASIS Submissions

CMS is asking HHAs to refrain from using the State OASIS System for editing their OASIS submission files. Some agencies have been submitting the same OASIS file repeatedly as TEST until they are able to fix all errors, then they submit the file as PRODUCTION. This is not the proper use of the State OASIS System.

Agencies who are not confident that their internal OASIS software program is performing appropriate edit checking, may install the Home Assessment Validation and ENtry (HAVEN) software provided by CMS. The HAVEN software is freeware that may be downloaded from the following website www.cms.hhs.gov/oasis/havensof.asp (exit DHFS).

For additional information on this software, contact the HAVEN Help Desk at (877) 201-4721.

Elder Abuse Resource Information

Elder abuse is a growing problem across the nation. According to the National Center on Elder Abuse (NCEA), a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence of elder maltreatment. It has been estimated that roughly two-thirds of all elder abuse perpetrators are family members, most often the victim’s adult child or spouse.

Everyone has a responsibility to keep vulnerable elders safe from harm, but often people fail to recognize the signs of elder abuse. While we don't know all of the details about why abuse occurs or how to stop its spread, we do know that help is available for victims. Concerned people can spot the warning signs of a possible problem and make a call for help if an elder is in need of assistance. Please see the Elder Abuse Resource Information found at http://dhfs.wisconsin.gov/caregiver/ElderAbuse.htm and:

• Learn the signs of abuse, neglect & exploitation of older individuals.
• Locate sources of assistance.
• Determine what social services, law enforcement & the justice system can do for victims.

In addition to BQA reporting requirements, entities should notify local law enforcement authorities in any situation where there is a potential criminal violation of the law. Call the police immediately if someone is in immediate, life-threatening danger. If the danger is not immediate, but you suspect that abuse has occurred or is occurring, please relay your concerns to BQA and to your local adult protective services unit (located within the County social/human services department), long-term care ombudsman, and/or police, as appropriate.

For assistance, please contact:

• Bureau of Quality Assurance, Office of Caregiver Quality, 608-243-2019 or E-mail: caregiver_intake@dhfs.state.wi.us

• County Agencies - Check local phone listings for social or human services department or see http://dhs.wisconsin.gov/aging/elderabuse/index.htm

• Board on Aging and Long Term Care Ombudsman Program
  1-800-815-0015 or E-mail: BOALTC@ltc.state.wi.us

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Latest CMS Survey & Certification Letters

Below is a list of the Survey and Certification 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]. 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.

Procedures in Event of a Fire at Medicare- or Medicaid-Certified Health Care Facility

The Centers for Medicare and Medicaid Services (CMS) Survey & Certification letter 04-23 provides clarification in response to additional concerns raised from recent fires that have resulted in multiple injury and death. View the letter online at www.cms.hhs.gov/medicaid/survey-cert/ letters.asp [link no longer operable].

Please also be advised that all fires in health care facilities are also to be reported to the Wisconsin Division of Disability and Elder Services within 72 hours. Please use form DDES-2500 on the Internet at http://dhfs.wisconsin.gov/forms/DDES/DDE2500.pdf (PDF, 23 KB) and fax to (608) 267-7119.

Overnight Stays at Ambulatory Surgical Centers

Survey & Certification Letter S&C 04-22 clarifies the issue of overnight stays and their impact with respect to the Medicare definition of an Ambulatory Surgical Center (ASC). There should be no planned overnight stays in an ASC for Medicare patients. Any overnight stay for a Medicare patient should only result from unanticipated conditions requiring continued observation or care within the capability of the ASC and should be neither a planned nor routine occurrence. Please review letter 04-22 (exit DHFS; PDF) via www.cms.gov/medicaid/survey-cert/letters.asp for more information. If you have further questions, you can contact Jean Kollasch, Provider Regulation & Quality Improvement, (608) 267-0466 or Jane Walters, Health Services Section, at (608) 266-7952 [replaced by Cremear Mims, (608) 243-2028].

Health Insurance Portability and Accountability Act (HIPAA) and the Nursing Home Requirement for Posting Survey Results

The Centers for Medicare and Medicaid Services (CMS) Survey and Certification Letter S&C-04-18 issued February 12, 2004 replaces S&C-03-26, which was released on June 12, 2003. This letter clarifies that nursing homes are required to post survey results in a place readily accessible to residents, family members and legal representatives, and that the state is required to make survey results available to the general public. The HIPAA Privacy Rule has not altered either requirement.

Administrative Rules Update

The Bureau of Quality Assurance created a task force to review the "Draft" Long Term Care Rulemaking Order that includes the following members: the Department’s Office of Legal Counsel, the Division of Public Health, Wisconsin health care associations, health care providers and the Board on Aging and Long Term Care. This task force meets regularly to achieve consensus on the proposed revisions for the following health-facility related rules administered by BQA: HFS 132 "Nursing Homes" and HFS 134 "Facilities Serving People with Developmental Disabilities. You can view the "Statement of Scope" for this long term care rulemaking order on the Department’s website at http://apps3.dhfs.state.wi.us/admrules/public/Home [Link no longer available] or in the Wisconsin Administrative Register published on November 15, 2003 at http://www.legis.state.wi.us/rsb/code/register/reg575a.pdf (exit DHFS, PDF).

In the interest of keeping our administrative rules up to date, the Department’s Rules Unit is drafting an 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. You can view the "Statement of Scope" for the Department’s "Second" Omnibus Rule Making Order on the Department’s web-site at http://apps3.dhfs.state.wi.us/admrules/public/Search [Link no longer operable], or in the Wisconsin Administrative Register published on November 15, 2003 at http://www.legis.state.wi.us/rsb/code/register/reg575a.pdf (exit DHFS, PDF).

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]

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