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January
2007
PDF
Version of this month's Quarterly Update (PDF,
237 KB)
The Office of Quality Assurance's (OQA) Assisted Living Section (AL)
has experienced a growth in the number of assisted living facilities
throughout the state. Currently, there are over 2,700 assisted living
facilities; including Adult Day Care (ADC) facilities, Adult Family Homes
(AFHs), Community Based Residential Facilities (CBRFs), and Residential
Care Apartment Complexes (RCACs).
To meet the demands of the increasing number of assisted living
facilities with varied locations throughout the state, a change in the
workload distribution is necessary and will occur on January 1, 2007. This
change in workload assignments only affects assisted living facilities
licensed/certified by OQA, and does not alter
other Department of Health and Family Services' regional assignments. The
following link shows the counties under each regional office, as well as
an updated map: http://dhfs.wisconsin.gov/rl_DSL/Publications/06-029.htm.
The Office of Quality Assurance (OQA) is pleased to announce the 7th Annual
Focus 2007 Conference, "Coming Together: Mapping the Journey to
Excellence," for health care providers and OQA staff. This year's conference, developed in collaboration with
health care providers from many fields, is designed to bring together a
variety of experts to share strategies and provide learning opportunities
for all caregivers. The conference will include a special session on
August 7, 2007, and the main event on August 8, 2007, at the Holiday Inn
and Conference Center in Stevens Point, Wisconsin. Last year's Focus 2006
Conference was attended by over 750 heath care providers and OQA staff, and was rated a huge success. Our goal is to exceed last
year's achievement, and FOCUS 2007 promises to be the best yet with
countless opportunities to explore, learn, sample, network, and recharge
your energies for the challenges of 2007.
August 7th is devoted to abuse prevention, and will provide a variety
of proven methods to use to prevent abuse, neglect, and misappropriation
of property of vulnerable adults in all care settings. The program titled,
"Zeroing In On Abuse Prevention," will include a
thought-provoking motivational presentation in the morning and several
breakout sessions in the afternoon designed to provide practical
approaches for use in health care facilities. The breakout sessions range
from providing information on how to create a culture of safety to
providing support to caregivers and responding to challenging situations.
The special session is recommended for all direct caregivers and
supervisors who care for vulnerable adults in Assisted Living Facilities,
Facilities Serving People with Developmental Disabilities, Home Health
Agencies, Hospices, Hospitals, Nursing Homes, and Personal Care Worker
Agencies.
The FOCUS 2007 conference on August 8, offers an exciting opportunity
for participants to:
- Acquire information from experts to address current and emerging
issues;
- Apply learned practices and strategies in their health care
settings; and
- Gain opportunities for networking and the exchange of ideas.
The conference will be kicked off with opening remarks by the new
Secretary of Health and Family Services, Kevin Hayden. Donna Manning, a
senior consultant with Maun/Lemke Consulting, will present a valuable and
exciting keynote, titled, "The Seven Keys to Expected Exceptional
Customer Service." The day will include 24 topical breakout sessions
on cutting-edge issues and practices, numerous informative exhibits, and
networking opportunities. The program is designed for staff from Assisted
Living Facilities, Facilities Serving People with Developmental
Disabilities, Nursing Homes and OQA staff.
The cost of the conference is not yet determined, and additional
information regarding program content will be provided in future OQA
Quarterly Updates and on the OQA website. Watch your mailbox for the FOCUS
2007 Conference brochure which will be mailed out in early June. Online
registration will also be available at the same time. Focus 2007 will
provide numerous formats to engage all types of learners, a variety of
content, and a thought-provoking lineup of presenters. See you there!
On November 27, 2006, CMS published a new rule in the Federal Register
revising the requirements in the hospital conditions of participation (COPs)
for completion of history and physical examinations, authentication of
verbal orders, securing medications, and completion of post-anesthesia
evaluations.
The new rule becomes effective January 26, 2007, and can be found at: http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/E6-19957.pdf.
On December 8, 2006, CMS published a second new rule in the Federal
Register revising the Condition of Participation: Patient's Rights.
Standard (e), Restraint for Acute Medical and Surgical Care and Standard
(f) Restraint and Seclusion, have been completely revised and reorganized.
This final regulation strengthens the staff training standard and
specifies components of the training. The rule also expands the category
of practitioners who may conduct patient evaluations when a restraint or
seclusion intervention has been implemented.
CMS currently requires that a patient be evaluated
"face-to-face" within an hour of a patient being restrained or
secluded for the management of violent or self-destructive behavior. This
regulation expands that list from a physician or "other licensed
independent practitioner (LIP)" to include a trained registered nurse
(RN) or physician assistant (PA). The rule requires, however, that when an
RN or PA performs the 1-hour-rule evaluation, the physician or other LIP
treating that patient be consulted as soon as possible.
A new Standard (g) has been added which expands the death reporting
requirements.
The new rule becomes effective January 8, 2007, and can be found at http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-9559.pdf.
OQA has developed three documents which compare the 2006 regulations to
the new 2007 regulatory changes. They are titled:
- Comparison of 2006 Regulations and 2007 Regulatory Changes to Part 482
- Conditions of Participation for Hospitals, Effective January 26, 2007.
- Comparison of 2006 Regulations and 2007 Regulatory Changes to Part 482
- Conditions of Participation for Hospitals, 482.13 Condition of
Participation: Patient's Rights, Standards
(a)-(d), Effective January 8,
2007.
- Comparison of 2006 Regulations and 2007 Regulatory Changes to Part 482
- Conditions of Participation for Hospitals, 482.13 Condition of
Participation: Patient's Rights, Standards (e) and (f) and the new
Standard (g), Effective January 8, 2007.
They can be found on the OQA website at: http://dhfs.wisconsin.gov/rl_dsl/Hospital/HOSPpubs.htm.
TeamStepps: A new patient safety team training tool kit available for
health care settings.
The Agency for Healthcare Research and Quality (AHRQ) and the
Department of Defense's military health system have released TeamSTEPPS, a
new, evidence-based team training and implementation tool kit that
demonstrates techniques of effective communication and other teamwork
skills. The new toolkit, which responds to the Institute of Medicine's
call for "interdisciplinary team training programs that incorporate
proven methods for team management" to prevent medical errors, is
designed to optimize team performance and outcomes across the health care
delivery system.
TeamSTEPPS includes the following components:
- An instructor guide
- Power Point presentations
- A DVD containing nine video vignettes
- A spiral-bound pocket guide
- A CD-ROM containing files of all print materials
- A 17" x 22" poster
The TeamSTEPPS tools can be viewed on the website of the Uniformed
Services University of Health Sciences http://www.usuhs.mil/cerps/teamstepps.html.
Single copies can be obtained free of charge by using the ordering form on
the AHRQ website at http://www.ahrq.gov/qual/teamstepps.
Following is a table of fires reported to OQA from Wisconsin health and
residential care facilities for the year 2006.
|
Sources/Impact
|
Nursing Homes
|
Hospitals
|
Assisted Living Facilities |
| Electrical |
11
|
4
|
3
|
| Smoking/Wastebasket |
2
|
1
|
6
|
| Kitchen |
3
|
0
|
5
|
| Laundry |
6
|
1
|
0
|
| Occupant/Arson |
1
|
2
|
4
|
| Mechanical/Construction |
1
|
1
|
3
|
| Injured |
6*
|
0
|
0
|
| Deaths |
0
|
0
|
0
|
| Facilities Destroyed |
0
|
0
|
0
|
| Automobile |
0
|
0
|
0
|
*staff injuries, minor in extent
60% of all fires resulted in activation of the building's fire alarm
system, with the number one source being electrical in nature. Staff
played a vital role in activating and responding to many of these
situations.
7% of all fires resulted in activation of the sprinkler system. A
majority of the fires lacked the heat build-up to activate a sprinkler
head. Most fires had minimal fuel load, or were caught in the early stages
of development.
Total property damage costs reported in 2006 came to approximately
$68,000.
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 http://dhfs.wisconsin.gov/forms1/OQA/oqa2500.pdf and fax it to
(608) 267-7119 or to the appropriate OQA Regional office. See http://www.dhfs.state.wi.us/rl_DSL/Contacts/reglmap.htm. See also BQA memo
00-017 posted at http://www.dhfs.state.wi.us/rl_DSL/Publications/00-017.htm.
In cooperation with the U.S. Consumer Product Safety Commission (CPSC),
Square D Company of Palatine, Ill., is recalling up to 27,600 General Duty
Safety Switches.
The safety switch can continue to supply electricity even after being
placed in the "OFF" position. This poses the risk of an
electric-shock or electrocution hazard to consumers.
Contact Square D toll-free at (877) 202-9046, between 7:30 a.m. and
5:00 p.m. ET, Monday through Friday, or visit the firm's website at http://www.us.squared.com.
Listed below are CMS webcasts that were produced between October and
Dec., 2006. They will be available for one year after the date of release.
You may access these webcasts at http://surveyortraining.cms.hhs.gov/.
10/20/06 Burnout: Staff
11/3/06 From Institutional to Individual Care, Part 1: Integrating
Individualized Care and
Quality Improvement
11/17/06 Burnout: Caregiver
12/15/06 Nursing Home Journal Volume IV: Unnecessary Medications
Listed below are selected Survey and Certification (S & C) Letters
distributed by CMS during the last quarter. Titles pertaining only to
state agency operations are omitted. If you have questions about
individual letters, contact Jan Eakins of OQA at (608) 266-2055, or email
her at eakinjl@dhfs.state.wi.us. Please note that the CMS Internet site
for all S & C memos is http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp.
The American Dietetic Association recently published a White Paper
discussing therapeutic diet orders in hospitals. The White Paper can be
found at: http://www.eatright.org. This site is available to ADA members
only.
Medicare Hospital Conditions of Participation related to Food and
Dietetic Services are found at 42 CFR 482.28 http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr482_06.html.
Interpretative guidance for these provisions is found in the Centers for
Medicare and Medicaid Services (CMS) State Operations Manual, Appendix A, http://cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf. On August
18, 2005, in S&C-05-42 http://www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp,
CMS clarified the interpretative guidance further to indicate that
therapeutic diets must be prescribed/ordered by the practitioner
responsible for the patient's care consistent with standing regulation 42
CFR 482.28 (b)(1).
In the case of hospital approved dietary protocols, the practitioner
responsible for the patient may write an order to implement a specific
dietary protocol for a specific patient. A hospital may not implement a
dietary protocol without such a written order by the attending physician
or doctor of osteopathy. The practitioner responsible for the patient may
choose to write an order instructing the qualified registered dietitian,
working within their hospital-granted privileges and scope of practice, to
conduct a nutrition assessment and write an order. The legal authority for
diet orders rests with the responsible practitioner.
Revisions to the RAI Manual 2.0
The January, March, and June 2006 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.
CMS MDS Web-based Training (WBT)
CMS developed an online training tool that provides information
contained in the Revised Long-Term Care Facility Resident Assessment
Instrument User's Manual, MDS Version 2.0. The MDS WBT is a user-friendly
training tool designed for nursing home clinicians and others interested
in learning about the RAI process and how to accurately complete MDS
assessments. The MDS WBT requires users to register on line and is able to
track an individual user's progress through the training program. For more
information about the MDS WBT program refer to CMS memorandum
S&C-07-03, dated December 7, 2006. The MDS WBT is located at: http://www.mdstraining.org.
Nursing Home MDS QI/QM Package Reports
The MDS Monthly Submission Statistic Report will now be available as
part of the QI/QM Package Report available in the online CASPER system.
The default for this report will be "unchecked." To request this
report as part of the QI/QM package, check the box to the left of the
report name. The MDS Monthly Submission Statistics Report includes all
production submissions where the submission date is within the specified
date range identified by the user. The report displays the month of
processing, number of batches processed, number of records processed,
number of records rejected, number of records accepted, and the rejection
percent. The CASPER system is accessed via the State MDS System and
requires the same login ID and password that are used to transmit MDS
assessment records.
OASIS Manual Revisions
The OASIS Implementation Manual was revised by CMS in June, 2006. The
updates reflect changes from the final Reporting Regulation, effective
June 21, 2006. After the June release, further corrections to Chapter 8
were completed and published in September, 2006. The Implementation Manual
and a crosswalk showing changes, the HHA System User's Guide Version 4.3,
and the OASIS Validation Report Messages and Description Guide can be
downloaded from the OASIS User Manual area of the CMS OASIS website. The
CMS OASIS website is located at: http://www.cms.hhs.gov/oasis/.
CMS Policy Change for Coding Surgical Wounds
Based on the current advances in wound care research, CMS will follow the
recently revised guidance on the Wound Ostomy Continence Nurses Society (WOCN)
Guidance Document on "OASIS Skin and Wound Status M0 Items"
(revised July 2006), regarding the lack of scientific evidence supporting
the finding of the healing ridge in the assessment of surgical wounds
closed by primary intention.
CMS encourages clinicians to follow the guidance suggested in the WOCN
Guidance Document on "OASIS Skin and Wound Status M0 Items"
(revised July 2006) in the assessment of surgical wounds, specifically in
the assessment of M0488 Status of Most Problematic (Observable) Surgical
Wound. This document is found at: http://www.wocn.org.
Home Health Compare Preview Reports
HHA Preview Reports will be made available to home health agencies
prior to public posting of the quality measure scores on the CMS Home
Health Compare website. The reports will be placed in a shared folder in
CASPER for each agency to view their demographic and quality measure data.
Agencies should use the following steps to access their Preview Reports in
CASPER:
1. Connect to the State OASIS System;
2. On the OASIS Welcome Page click on Online Reports;
3. Login into CASPER;
4. Select the Folders Tab;
5. Select the Shared Folder Link which displays as: *WI HHA####, and
6. Click on the name of the report for viewing.
CASPER requires the same login ID and password that are used to
transmit OASIS assessment records to the State OASIS System. Additional
information regarding the Preview Reports is available on the State OASIS
System Welcome Page.
OBQI and OBQM Reports by Branch are Now Available
Beginning December 18, 2006, the HHA OBQI and HHA OBQM reports will
allow the user to request that the report be displayed by branch for all
OBQI and OBQM reports. Two new columns have been added to the OBQI Outcome
Tally, OBQI Case Mix Tally, and the OBQM Patient Listing reports to
display the value in M0016-Branch ID Number of the Start of Care
assessment and the End of Care assessment for the identified Episode of
Care. Instructions for requesting reports by branch are available on the
State OASIS System Welcome Page.
The Department of Health and Family Services is proud to announce
exciting new resources now available to health care providers to assist in
bringing person-directed care to persons with dementia to create true
culture change. The Bureau of Aging and Disability, in collaboration with
the Office of Quality Assurance, has developed a multifaceted program that
provides a "how to" guide for providers to implement
person-directed care in long term care facilities. These resources were
developed by an advisory committee of experts including staff from nursing
homes, advocacy groups, and the Department.
These resources are listed at http://dhfs.wisconsin.gov/aging/Genage/ALZFCGSP.HTM.
Program Highlights
The web site includes two (2) hour-long webcasts designed to be viewed
by all facility staff, introducing the concepts of person-directed care,
and provides a basic framework for replicating the program in your
facility. The webcasts show an actual activity program designed to
maintain cognitive abilities, boost self esteem, and facilitate
rejuvenation of residents. A role playing exercise, demonstrating the
importance of care planning based on person directed care concepts, is
also included.
A significant portion of the program includes an extensive assessment
tool that is designed to be used by facility staff as a guide in
identifying the elements necessary to implement person-directed, dementia
care. The tool focuses on nine key areas ranging from the environment and
activity programs to communication, leadership, and team dynamics. Your
staff will be able to use this tool to identify the existing strengths of
your program and to designate areas for improvement. The web site includes
instructions on how to convert this information into a quality improvement
plan, complete with benchmarks to re-assess and measure progress, and
identify new areas of focus over time. Additional resources include
templates and examples to develop action plans, training tools, and
numerous publications and links related to dementia and person-directed
care.
We hope you find these resources beneficial and add them to your own
reference collection or quality improvement library.
After careful consideration, the Department has decided to discontinue
its full Annual Survey of Nursing Homes statistical report published each
year by the Division of Public Health, Bureau of Health Information, and
Policy. The decision to discontinue the survey was based on lack of
funding to conduct, analyze, and publish the results; and because most of
the information collected by this survey is now available through other,
more modern and efficient automated data collection systems. Therefore,
the annual survey nursing homes expect each year from the Bureau of Health
Information in late December will not be mailed this year.
Some of the data collected by the Annual Survey of Nursing Homes will
be needed to meet requirements of 2006 Wisconsin Act 386, which relates to
nursing home resident relocations of persons with developmental
disability, and requires reporting of facility staff turnover rates. Also,
beginning in 2007, some of the data will be needed for the Department's
2007 nursing home quality initiative "Recognition for
Performance."
Therefore, Wisconsin nursing homes will be required to complete a pared
down version of the survey for 2006, as well as in subsequent years.
Information will be forthcoming early in 2007, regarding the Department's
revised 2006 annual survey that facilities will be required to complete.
Additionally, any information that OQA is required to collect, which
previously was part of the annual survey, will be collected in a different
manner.
|
Memo
|
Title
|
Providers Affected
|
| 06-022 |
Medication Return, Donation and Disposal |
Nursing Homes |
| 06-025 |
Patient Privacy During Inpatient Psychiatric Treatment |
Adult Family Homes, Community Based Residential
Facilities, Hospitals, Area Administrators, County Mental health
Coordinators |
| 06-027 |
Disaster preparedness Memo |
All Providers |
| 06-028 |
Adult-At-Risk, including Elder Adult-At-Risk Reporting
Requirements for Entities Regulated by the Office of Quality
Assurance |
All Providers |
| 06-029 |
Assisted Living Section Regional Boundaries Effective
January 1, 2007 |
Adult Day Care Centers, Adult Family Homes, Community
Based Residential Facilities, Residential Care Apartment Complexes |
| 06-030 |
Self-Report/Facility Reporting Requirements |
Adult Family Homes, Community Based Residential
Facilities, Residential Care Apartment Complexes |
| 06-031 |
Post Survey Questionnaire Now Available via On-Line
Survey |
All providers |
| Upcoming Memos |
| |
Certification of Waivers and Variances Submitted to
Program Certification Unit Memo |
|
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/.
2005 Wisconsin Acts 264 and 387 revised Chapter 55 and created Chapter
54 of the Wisconsin Statutes. The Acts amend, repeal, and create major
portions of Wisconsin's protective services, protective placement, and
guardianship laws. Act 264 changes became effective November 1, 2006, and
Act 387 changes became effective December 1, 2006. The Coalition of
Wisconsin Aging Groups (CWAG) has published an article, revised 11/20/06,
available on their web site, entitled Authority to Consent to Admission
(Placement) to Nursing Homes, CBRFs, RCACs and Hospice. This article
provides guidance on who has the authority to consent to an individual's
admission to nursing homes and certain other facilities, and the
circumstances under which someone can make admission decisions.
The article is located on CWAG's website at: http://www.cwag.org/uploads/Guardianship%20Support%20Center/Admissions%20outline%20Nov%2006.pdf.
The article published by CWAG replaces the information contained in BQA
Memorandum-94-051. We recommend you check CWAG's website monthly for
updates to this article.
HFS 83 - Community Based Residential Facilities
The HFS 83 Rewrite Workgroup completed the initial draft of the
proposed rules for Chapter HFS 83. The goal of the workgroup was to
eliminate excessively prescriptive language and improve readability and
organization. The proposed rule clarifies medication administration
requirements and revises staff training standards, establishing a more
cost-effective system for providers. Currently, the proposed rule is under
review by the DHFS 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/.
HFS 83 - Community Based Residential Facilities, HFS -
88 Adult Family Homes, HFS 89 - Residential Care
Apartment Complexes, HFS 132 - Nursing Homes, HFS 134 - Facilities for the Developmentally Disabled
On December 15, 2006, the Wisconsin Administrative Register published a
Statement of Scope of proposed rules to amend Chapters 83, 88, 89, 132 and
134 relating to involuntary administration of psychotropic medication.
2005 Wisconsin Act 264 created s. 50.02 (2) (ad), Stats., which directed
the Department to promulgate rules that require the above named facilities
to provide information to determine a facility's compliance with s. 55.14,
Stats. An Advisory Committee, including all stakeholders, will be formed
to review draft language and solicit comment for inclusion in the affected
rules. For more information, you may view the Statement of Scope on the
Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov/.
HFS 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 HFS 85, Non-profit
Corporation as Guardian. Through this initiative, the Department proposes
to make the rule reflect current standards of practice for corporate
guardianship agencies, recognizes the increase in the number of adults in
need of guardianship, and the increase in the complexity of their needs.
An Advisory Committee, including representatives from all stakeholders,
has been formed and will meet to begin making recommendations for revision
to the rule. For more information, you may view the Statement of Scope on
the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov/.
HFS 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 HFS 124 to eliminate overly prescriptive
regulations, clarify the Department's enforcement authority, and make the
rule more consistent with the federal Medicare requirements. For more
information, you may view the Statement of Scope on the Wisconsin
Administrative Rules website at http://adminrules.wisconsin.gov/.
HFS 129 - Certification Programs for Training and Testing
Nurse Assistants, Home Health Aides and Hospice Aides
On March 31, 2006, the Wisconsin Administrative Register published a
Statement of Scope of proposed rules to amend Chapter HFS 129. Through
this initiative, the Department proposes to make the rule more consistent
with federal regulations, to include the feeding assistant and medication
aide training and testing program requirements, and to reflect the
Department's decision to standardize administration and operation of nurse
aide competency evaluation by contracting for this service. An advisory
committee, including advocates, educators, association representatives,
workforce development specialists, and representatives from private
industry, meets regularly to review the proposed revisions to the rule and
make changes, as necessary. For more information, you may view the
Statement of Scope on the Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov/.
HFS 132 - Nursing Homes
OQA drafted proposed revisions to HFS 132 to eliminate duplicative
state regulations that are already contained in other State law or federal
nursing home regulations. The intent is to streamline the code by
eliminating regulations that provide unnecessary specificity, and to adopt
the applicable federal regulatory language. Public hearings were held the
last week of July in Milwaukee, Eau Claire, Rhinelander, Green Bay, and
Madison. For more information, you may view the Statement of Scope on the
Wisconsin Administrative Rules website at http://adminrules.wisconsin.gov/.
HFS 133 - Home Health Agencies
The HFS 133 Rewrite Workgroup, working with the advisory committee
(including providers, consumers and association representatives) has
completed the draft of the proposed rules for Chapter HFS 133. The goal of
the committee was to make the rule consistent with federal regulations and
to reflect current terminology and practice. The Rule Summary and draft
rule are currently under review by the DHFS 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/.
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