DQA Quarterly Information Update

July 2004

[PDF Version of this month's Quarterly Update (PDF, 240 KB) - blue text indicates links to other pages or Internet sites]

• New Director for BQA
• BQA Numbered Memos April-June 2004
• Insulin Medication Errors in Nursing Homes
• Variance for Supervision Requirements for Mental Health Professionals
• BQA to End Sales of RAI User’s Manuals
• New Assisted Living Section Regions
• Changes in Mailing Procedure to Assisted Living Providers
• Hospital Certificate of Approval and Change of Ownership Applications 
• Construction Plan Submittal Notice
• Hospital Statutory and Survey/Licensure Changes, (including Critical Access Hospitals)
• Federal Medicare State Operations Manual on Internet
• New Clients Right Internet Site; Revised Brochure
• Elder Abuse – Awareness is Everything!
• Provider Conference - "Focus 2004: Collaborating for Quality"
• CMS Webcasts: Pressure Ulcer & Other Wound Courses
• Outcome and Assessment Information Set (OASIS) Information
• Reminder of Responsibility for Protecting Data
• OASIS Information Posted
• HAVEN Release Fall 2004
• OASIS Training
• Latest CMS Survey & Certification Letters
• CMS Life Safety Code and State Performance Standards
• Administrative Rules Update
• Wisconsin Mental Health Teleconference

New Director for BQA

Sinikka Santala, Administrator of the Division of Disability and Elder Services, Wisconsin Department of Health and Family Services (DHFS) recently announced the appointment of Cris Ros-Dukler as the Director of the Bureau of Quality Assurance, effective June 21, 2004.

Cris comes with an extensive background in overseeing health and human services in public, private non-profit, and for profit organizations in Texas and Wisconsin. She has a Master of Science degree in Educational Psychology from the University of Hawaii. Cris’s most recent position was with the DHFS Division of Children and Family Services as a facilitator of a statewide planning partnership with counties, tribes, advocacy groups, consumers and other stakeholders in the child welfare arena to improve child welfare outcomes.

Her experience in Wisconsin includes five years as UPC Health Network’s Executive Director of Operations for Wisconsin and Illinois responsible for profit and loss management of home health, durable medical equipment, and ancillary services to nursing homes, and other residential settings; product development; acquisitions and joint ventures and quality assurance.

Cris also served as the Regional Vice President for Lutheran Social Services (LSS) for the Northeast region and Upper Michigan for two years, being responsible for overseeing operations and provision of services to families and children, residential and support services and adoption. In addition, she managed the contract with the Bureau of Milwaukee Child Welfare to license, train and support foster care providers.

Please join us in welcoming Cris to her new responsibilities!

BQA Numbered Memos April-June 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/.

BQC Memo 90-024 (PDF, 8 KB) for nursing homes, "Statewide Waiver of HSS 132.84(2)(e)1, Amended to Include HSS 132.84(2)(f)2," issued May 24, 1990, has been restored to the BQA memos list as it was inadvertently omitted. It concerns requirements for allowing members of both sexes to share individual toilet rooms. [Replaced by 07-017 6/06)

We have obsoleted the following BQA memos:

• 91-081 and 00-023, due to the termination of BQA’s document sales program.

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Reminder: Memo on Insulin Medication Errors in Nursing Homes

It has come to our attention that many staff in Bureau-regulated entities are not aware of a memo on insulin errors on the Internet at http://dhfs.wisconsin.gov/rl_DSL/NHs/NH03014.htm. This memo, BQA-03-014, provides information on recommended procedures for administering insulin. Please take a few minutes to review it.

Medication errors involving insulin have been identified as one of the top ten medication errors in many facilities. Insulin is identified as a high-risk medication in many medication safety programs due to the errors that occur in administering it. Many of the errors involve the newer types of insulin and are related to the timing of insulin administration. Providers should always check with their consultant pharmacist, physician and the manufacturer guidelines prior to administering insulin to assure it is being given properly.

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.

BQA to End Sales of Resident Assessment Instrument User’s Manuals

The Bureau of Quality Assurance (BQA) will discontinue sales of the Centers for Medicare and Medicaid Services (CMS) Long Term Care Resident Assessment Instrument User’s Manual. This change is due to the increasing frequency of edits being made by CMS to the manual and the difficulty in keeping print copies current. BQA will continue to provide the most current Long Term Care Resident Assessment Instrument User’s Manual at BQA-sponsored RAI and MDS (Minimum Data Set) training programs.

The CMS Long Term Care Resident Assessment Instrument User’s Manual is available on the CMS website at www.cms.hhs.gov/medicaid/ mds20/man-form.asp or www.qtso.com/mdsdownload.html. Note that the manual is over 450 pages.

New Assisted Living Section Regions

The Bureau of Quality Assurance (BQA) has created new assisted living region boundaries to better distribute assignments among its staff responsible for regulating adult day care, adult family homes, community based residential facilities (CBRFs) and residential care apartment complexes (RCACs). We announced this change in BQA Memo 04-017.

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

The Assisted Living Section (ALS) regions roughly correspond with the current Department regions, with the differences being:

• Marinette, Menominee, Oconto, Shawano and Waupaca counties in the DHFS Northeastern region are now assigned to the ALS Northern region.
• Sawyer County in the DHFS Northern Region is now assigned to the ALS Western region.
• Ozaukee County in the DHFS Southeastern region is now assigned to the ALS Northeastern region.
• Jefferson and Washington counties in the DHFS Southeastern region are now assigned to the ALS Southern region.

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

As noted earlier this year, Vernon County, formerly of the DHFS Western Region, has been reassigned by the Department to the DHFS Southern Region.

Changes in Mailing Procedure to Assisted Living Providers

Entities that have been used to receiving multiple copies of bureau memos and other mailings in their offices for distribution to their multiple providers will now see a reduction in the paper flow. The Bureau has changed its database setups to produce only single labels where two or more providers give the same address as their primary mail contact for licensing purposes. This will primarily affect community based residential facilities (CBRFs) and adult family homes.

The reason for this change is not only the expense of mailing multiple copies to the same address but also the additional costs of dealing with returned mail. In addition, the Bureau provides mailing labels to other agencies in the Department of Health and Family Services, so the concerns about the expenses and staff time involved are not just those of the Bureau alone.

Providers are allowed the freedom to state the address the Bureau is to use as the providers’ official licensing contact. It is our expectation that, in return, offices representing multiple providers will see to it that copies of materials from the Department are made and distributed further.

It may be that an office representing different provider types (such as CBRFs, adult family homes and residential care apartment complexes) may continue to receive multiple copies of mailings, but not more than one copy per each provider type.

As always, providers can also consult the Bureau materials posted to the Internet via http://dhfs.wisconsin.gov/rl_DSL. Select the appropriate provider type, then choose the "Publications" and/or the "Providers" link.

Hospital Certificate of Approval and Change-of-Ownership Application Form Now Available on the Internet

A new hospital Certificate of Approval application form for new applicants and Change of Ownership (CHOW) transactions can now be accessed from the BQA web site at http://dhfs.wisconsin.gov/forms/ ddes/DDE2092.pdf (PDF, 455 KB). The new application is a fillable template and can be completed, notarized and then sent to:

Bureau of Quality Assurance
Provider Regulation & Quality Improvement
1 W. Wilson Street, Room 950
P.O. Box 2969
Madison WI 53701-2969

Telephone, e-mail or fax inquiries about the application may be directed to Paul Yochum, (608) 266-7297, fax (608) 267-7119 or E-mail yochupa@dhfs.state.wi.us.

Construction Plan Submittal Notice

The Bureau of Quality Assurance (BQA) is honoring the Department of Commerce’s current practice of accepting just one full set of building plans if the set is accompanied with at least 3 additional acceptable cover sheets. Upon BQA plan review approval, only the unneeded cover sheets would be returned to the designer. This will significantly reduce postage and handling for all parties.

To review further details of this practice, see the Commerce "Submittal Kit" Question and Answer page at http://commerce.wi.gov/SB/SB-DivForms.html (exit DHFS; PDF, 144 KB).

A proposed rule change to the Wisconsin Commercial Building Code (WCBC) section Comm 61.31(2)(b)2.b. codifies this practice. Further details of the Commerce proposed rule changes are available at www.commerce.state.wi.us/SB/SB-CodeDevelopment.html (exit DHFS).

Hospital Statutory and Survey/Licensure Changes (including Critical Access Hospitals)

In the May 18, 2004 Federal Register / Vol. 69, No. 96, the Centers for Medicare & Medicaid Services (CMS) published proposed regulations that impact critical access hospitals (CAHs) including:

• Section 405 (e) which increased number of acute care beds to 25;
• Section 405 (g) which provides for distinct part units; and
• Section 405 (h) which terminates a States authority to waive the location requirement of "necessary provider".

The document is very long. Relevant pages are 28196, 28201-02 and 28371-72. Access these pages on the Internet at www.access.gpo.gov/su_docs/fedreg/a040518c.html (exit DHFS), scrolling down to "Centers for Medicare & Medicaid Services, PROPOSED RULES - Medicare: Hospital inpatient prospective payment systems and 2005 FRY rates." The text version comes up quickly, the PDF version will take some time to load.

Section 405(g) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, allows critical access hospitals (CAHs) to set aside units of up to ten beds each to be used exclusively for inpatient rehabilitation and psychiatric services as of October 1, 2004. Go to www.raconline.org/news/news_details.php?news_id=1333 (exit DHFS) for the CMS instructions for implementation.

Beginning October 1, 2004 a CAH can declare distinct units either Rehabilitation or Psychiatric which are subject to Prospective Payment System (PPS) exclusion. The Bureau of Quality Assurance will conduct a separate unannounced PPS exclusion survey for new (first time) and existing distinct units as per Chapter Three, Section 3100 of the new Federal Medicare State Operations Manual (SOM) at www.cms.hhs.gov/manuals/107_som/som107index.asp (exit DHFS).

The SOM in Chapter Two, section 2700 (for all provider types) and in Appendix W (specific to CAHs) updates the CMS certification procedures. Effective immediately, all surveys, including hospital and CAH surveys, conducted by BQA will be unannounced. JCAHO is moving to make their surveys unannounced.

An update to the CAH article on page 7 of the January 2004 BQA Quarterly Information Update: Providers have had questions about how their CAH license will be updated based on the Medicare Modernization Act, which allows a maximum number of 25 beds regardless of swing-bed approval as of January 1, 2004. BQA will reissue updated licenses to reflect actual number of total beds upon the receipt of a completed & signed 2004 DDE-2445 (REV. 03-03) Hospital Annual Report. Hospitals will receive their 2004 Hospital Annual Reports in a mailing sent around August 1, 2004 by BQA. The Report return date to BQA will be on or before October 1, 2004.

Federal Medicare State Operations Manual on the Internet

The Centers for Medicare and Medicaid Services (CMS) Medicare State Operations Manual (SOM) can now be accessed in its entirety online. As described in CMS Transmittal R1SOM dated 5/21/04, on the Internet at www.cms.hhs.gov/manuals/pm_trans/R1SOM.pdf (exit DHFS, PDF), the SOM is now an Internet-only manual that replaces the current paper-based manual. View the SOM at www.cms.hhs.gov/manuals/107_som/ som107index.asp (exit DHFS).

Once you have located the material you need in the Table of Contents, we recommend that you click on the link in the column headed "View PDF file." This will open that section of the manual in a new window. If necessary, you can print a partial or complete paper copy of the section directly from this window. You can also save a copy of the PDF file to a suitable location on your computer and open it using the Adobe Reader.

The SOM is the basic document governing investigation of providers receiving federal funding. Information specific to individual provider types is contained in the appropriate appendices.

Staff and management should also review the CMS Online Manual System at www.cms.hhs.gov/manuals/ (exit DHFS) for the following important communications:

• Program Transmittals
• Crosswalks between paper manuals and Internet versions

• Program Memoranda (historical, no longer to be issued)

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New Client Rights Internet Site Coming; Revised Brochure

By the time you receive this update, the Division of Disability and Elder Services’ new website on client rights should be available at http://dhfs.wisconsin.gov/clientrights. This website will replace BQA memos 99-045 and 99-044. The Client Rights Publications and Forms page will also be moved from its current location to the Client Rights site.

The primary focus of this site is on the rights of patients receiving treatment for mental health or substance abuse, both adults and minors, inpatients and outpatients in community settings. The site will feature information about guardianship, informed consent, confidentiality, detention of non-Wisconsin residents, and rights limitation or denial. It will also contain contact information for the Client Rights Office and the State Grievance Examiner.

A revised brochure, PDE-195A, "Client Rights and the Grievance Procedure for In-Patient Services," will also be available in two formats from the Client Rights site. This is a short introduction to the rights in-patients have and the process by which to file complaints.

Elder Abuse – Awareness is Everything!

In the April 2004 edition of the BQA Quarterly Information Update, you were introduced to the Department of Health and Family Services Elder Abuse Resource Information found at http://dhfs.wisconsin.gov/caregiver/ ElderAbuse.htm.

This article focuses on the need for increased awareness of the growing problem of elder abuse. A total of 3,721 cases of suspected abuse and neglect were reported to the Wisconsin Elder Abuse Reporting System in 2002, an increase of 15.45 percent over 2001. Of these, 12 were fatal and 293 were considered life-threatening. One out of every 13 incidents involved either a fatal or life-threatening situation (Wisconsin DHFS Report on Elder Abuse, 2003). The number of people over age 65 is continuing to increase. With this increase in the older population, it can be expected that cases of abuse against older individuals will also continue to rise. Because of the potential for this increase, awareness of the problem of elder abuse is essential.

BQA recognizes that most providers who observe misconduct by facility staff report these incidents as required under the Wisconsin Caregiver Law (see http://dhfs.wisconsin.gov/caregiver/index.htm). However, other elder abuse can be difficult to identify, and oftentimes cases go unreported. This is especially true for instances of elder abuse involving other individuals, such as family members, friends, volunteers, etc. Statistics indicate that the majority of alleged abusers are relatives of the victim: sons (22.19%), daughters (20.75%), spouses (14.44%) and other relatives (16.93%) (Wisconsin DHFS Report on Elder Abuse, 2003).

The following examples involving family members occurred in Wisconsin and were not investigated by the facility or reported to law enforcement, but were discovered during state surveys:

• A nurse aide reported to the RN that she observed a female resident with dementia who had her hand down her son-in-law's pants. The RN notified the Director of Nursing (DON) who informed the Administrator; however, the facility failed to notify the police or thoroughly investigate the nurse aide’s observation. The DON was concerned that the facility needed to determine if the behavior was consensual. The DON reported that she did not interview the resident until the following day and, then, did not specifically ask the resident about what the nurse aide observed. The Administrator reported that he did not interview the son-in-law, as he was unable to track him down after the incident, even though the resident’s record included the son-in-law’s address and telephone number. Two weeks later, a nurse aide observed the son-in-law in the resident’s room with his pants down. The nurse aide notified the LPN who went to the room and observed the son-in-law standing behind the curtain with his pants down exposing himself to the resident. The resident was lying on her bed on her side with her hands placed in the son-in-law’s genital area. The facility's failure to thoroughly investigate the first allegation of abuse created a situation whereby the second alleged incident of abuse was able to occur two weeks later.

• A visitor was seen massaging a resident's breast on top of her clothing. He then placed his right hand under her top and rubbed her chest and breasts, and at the same time aggressively kissed the resident on the mouth. There was no evidence that staff documented these incidents or immediately reported this allegation to appropriate facility personnel, or that an investigation was started in a timely manner after these observations were made. The facility did not interview the three facility staff members who were eye-witnesses to the allegations of sexual abuse of the resident, and no other facility staff were approached to determine whether additional observations of this type of activity had been made. A few weeks later, the visitor was arrested for "second degree sexual assault." A staff person documented observing visits between the visitor and resident which consisted of caressing the resident’s left side down to shoulders with several kisses on the lips on eight separate occasions, after the court hearing. There was no evidence that the facility contacted the resident's physician to inform the physician of the abuse allegations made, or that the resident underwent a Sexual Assault Nurse Examination to rule out sexual abuse. After the allegations were made, the facility did not act to protect the resident from further incidents of abuse, since the visitor was seen in the building the following month.

Providers need to recognize that this abuse can and does occur and to be aware of their responsibility to report suspected elder abuse committed by those other than facility staff. Four categories of elder abuse are defined in Wisconsin Law, Chapter 46.90:

1. Physical abuse is the willful infliction of physical pain, injury or unreasonable confinement. It includes, but is not limited to, beating, choking or burning, inappropriate medication or tying or locking a person up. It also includes sexual abuse, which occurs when a person has been forced, tricked, threatened or otherwise coerced into sexual contact against one’s will.

2. Material abuse, also known as financial exploitation, is the misuse of an elder's money or property. It includes deception, diverting income, mismanagement of funds and taking money or possessions against a person’s will.

3. Neglect occurs when a caregiver's failure to provide adequate food, shelter, clothing, medical or dental care results in significant danger to the physical or mental health of an older person in his/her care.

4. Self-neglect means a significant danger to an elder person's physical or mental health because the elder person is unable or fails to provide him/herself with adequate food, shelter, clothing, medical or dental care.

There are three basic components to responding to elder abuse. The first is to recognize it. The second is to react. And the third is to refer. Detailed information regarding these components may be found in DDES Information Memo 2004-03, "Domestic Violence in Later Life and Sexual Assault Incidents Occurring in Facility Settings – A Resource Memo," http://dhfs.wisconsin.gov/dsl_info/InfoMemos/InfomeIndex.htm., including:

• learning the signs of abuse, neglect & exploitation of older individuals,
• locating sources of assistance, and
• determining what social services, law enforcement & the justice system can do for victims,

Please take the time to review this memo and additional resources.

For more information, please contact:

Elder Abuse
Jane A. Raymond, Advocacy and Protection Systems Developer
DHFS/DDES/Bureau of Aging and Long Term Care Resources
P.O. Box 7851
Madison WI 53707-7851
Voicemail: 608-266-2568
FAX: 608-267-3203
Email: raymoja@dhfs.state.wi.us

Caregiver Misconduct
Shari Busse, Caregiver Investigation Lead
DHFS/DDES/BQA/Office of Caregiver Quality (OCQ)
2917 International Lane, Suite 300
Madison, WI 53704
Voicemail: 608-243-2036
FAX: 608-243-2020
Email: bussese@dhfs.state.wi.us

Provider Conference -- "Focus 2004: Collaborating for Quality"

The Bureau of Quality Assurance (BQA) is excited to announce this year’s Annual BQA Provider Conference "Focus 2004: Collaborating for Quality," being held on August 9, 2004. The conference site is the American Family Insurance National Headquarters Training Center (Building A), located at 6000 American Parkway in Madison, WI. A brochure and online registration are available at http://dhfs.wisconsin.gov/rl_DSL/Training/index.htm. For registration questions, contact the Bureau of Quality Assurance Training Coordinator at (608) 267-1438. Registration deadline is July 26, 2004.

Targeted for Assisted Living, Facilities for the Developmentally Disabled (FDD) and Nursing Home staff, this conference will give health care managers and caregivers the opportunity to gather important facts, learn new information, communicate and network with others, increase their understanding of the topics covered, and share ideas and comments. Department of Health and Family Services Secretary Helene Nelson will provide the audience with valuable opening remarks to kick off the event.

The conference will also feature a morning and afternoon keynote address, along with breakout sessions specific to Assisted Living and Long Term Care issues. Sixteen informational exhibit booths will be available for viewing by conference participants. All breakout sessions and exhibits will provide practical and beneficial information centered on the conference title.

Looking forward to seeing you there!

CMS Webcasts: Pressure Ulcer and Other Wound Courses

On August 3, 2004, from 12:00-3:00 p.m. CST, the Centers for Medicare & Medicaid Services (CMS) will broadcast a three-hour presentation via satellite and Internet web cast on the Clinical Aspects of Pressure Ulcer Care in Long Term Care Facilities. The goal of this broadcast is to educate LTC surveyors and providers on how to assess, prevent, manage and treat pressure ulcers.

The live broadcast will be available for viewing on August 3, 2004 from 12:00 to 3:00 p.m. and for up to one year via the Internet at http://surveyortraining.cms.hhs.gov/ (exit DHFS).

Home health agencies and others that work with the Outcome and Assessment Information Set (OASIS) database had the opportunity to view a similar broadcast on April 23, 2004, "The State of Science in Wound Care Management." The presentation provided the viewer with a better understanding of the current state of science in wound care, accurate coding for OASIS wound items (M0440 – M0488), and OASIS assessments required between days 55-60.

If you missed this informative broadcast, you can view it via webcast until April 23, 2005 at http://surveyortraining.cms.hhs.gov/ (exit DHFS), along with program materials and continuing education units (CEUs).

Outcome and Assessment Information Set (OASIS) Information

Reminder of Responsibility for Protecting Patient Data

Under the Code of Federal Regulations CFR 484.11, home health agencies (HHAs) are required to maintain the confidentiality of all patient identifiable information contained in the clinical record, including OASIS data. The agency may not release this data without the consent of the patient for any reason other than for what it was intended, which is to appropriately deliver patient care.

The following situations, which breached the confidentiality of patient records, have occurred nationally at several HHAs:

• An HHA sold its computer and did not remove the OASIS data.
• A staff person who encoded home health assessments from her home was terminated, but her computer access remained intact.
• A computer containing OASIS information was stolen.

Agencies must have policies and procedures in place for limiting access of confidential electronic or written data to only those persons the agency designates. Agencies will be asked to show how they are protecting the patient’s data when surveyed. A violation of confidentiality of patient data is a federal issue and will be investigated.

OASIS Information Posted

The State posts information regarding OASIS on the State OASIS System Welcome page under Bulletins. Check this site frequently. Information posted recently includes:

• S&C memo 04-26, dated April 8, 2004: "Clarification on Collection of OASIS Data for Non-Medicare/Non-Medicaid Patients."
• CMS letter to NAHC (June 3, 2004) clarifying several HH issues.
• Clarification of OASIS data items M0780 and M0830.
• OASIS Considerations for Medicare PPS Patients, revised June 2004.

HAVEN Release – Fall 2004

The Fall release of the Home Assessment Validation ENtry (HAVEN) software is scheduled for October 1, 2004. This release will include:

• An enhancement to provide a drop down box for M0016 (Branch ID).
• Modifications to allow a simplified assessment requirement for a SCIC with intervening hospital stay and return home during last 5 days of an episode (days 56-60).

OASIS Training

The Bureau of Quality Assurance is tentatively planning a mini-series training on OASIS Quality Reports. The training on reading and interpreting OASIS quality reports would take place in October 2004 and would consist of two audio teleconferences. The first conference would discuss the Outcome-Based Quality Monitoring (OBQM) Reports and the Case Mix Report. The second would discuss the Outcome-Based Quality Improvement (OBQI) Reports. The target audience would be new home health agencies (HHAs) and staff.

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

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.

CMS Life Safety Code and State Performance Standards:

The Centers for Medicare and Medicaid Services (CMS) has issued a Survey & Certification letter 04-33 providing a consolidated document regarding the three previous letters, (1) Investigations of multiple death fires addressed in S&C-04-23 issued 3/11/2004; (2) Definitions of terms used in the Life Safety Code addressed in S&C-04-15 issued 12/11/2003; and (3) Investigation of complaints addressed in S&C-04-09 issued 11/13/2003. You may view the letter online at www.cms.gov/medicaid/survey-cert/sc0433.pdf (exit DHFS, PDF).

Administrative Rules Update

HFS 132 and 134- "Long Term Care Rule Making Order"

The Wisconsin Legislative Council Rules Clearinghouse has reviewed the rulemaking order for Chapters HFS 132 and 134, relating to sundry changes to the administrative rules for nursing homes and facilities for the developmentally disabled. After the public hearing on June 30, 2004, the Department will submit the legislative report and the final proposed rules to the Legislative Standing Committees.

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 in the process of drafting rules for a new administrative rule, HFS 148, the "Cancer Drug Repository Program." The proposed rules will be the subject of a Statement of Scope published on June 30 in the Wisconsin Administrative Register. 2003 Wisconsin Act 175 created s. 255.055, Stats, which requires the Department to establish and maintain a cancer drug repository program and promulgate administrative rules for the program. 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).

Other Bureau of Quality Assurance (BQA) Rule Updates:

The Department’s 2003 "Omnibus Rule Making Order"

The Wisconsin Legislative Council Rules Clearinghouse has reviewed the rulemaking order 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. A public hearing pertaining to this rulemaking order is scheduled for July 12, 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]

Wisconsin Mental Health Teleconference Schedule

The events listed on the Department of Health & Family Services’ Mental Health Teleconference Schedule qualify as continuing education for community based residential facility and adult family home providers. These events are held every other Thursday from 11:00 to 12:00 p.m. There is no fee to participate; the only charge would be the expense of the phone call to the number supplied. Topics include "Suicide Assessment" on July 29, 2004; "Advance Directives for Mental Health" on October 7, 2004; and "Antidepressants" on October 21, 2004. Handouts are available online for many presentations. Tapes of presentations can also be purchased for up to a year after the date of the teleconference. 

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