If You Have Complaints about Wisconsin Health Care

Information about Division of Quality Assurance (DQA)

DQA Web Pages Information

Provider Types Regulated by DQA

DQA Listservs

Consumer Information

DQA Facility Directories

DQA Provider Training

DQA Numbered Memos

DHS Forms

Construction/
Remodeling of Health Care Facilities

WI Nurse Aide Training and Registry Info

Caregiver Program/ Background Checks

WI Adult Programs Caregiver Misconduct Registry

OQA Quarterly Information Update

November  2006

[PDF Version of this month's Quarterly Update (PDF, 64 KB) - blue text indicates links to other sections or to Internet pages]

• BQA becomes OQA

• Updated OQA Senior Management Communication Information

• Advancing Excellence for America's NHs Campaign

• Recall of CoaguChek PT test Strips

• FOCUS 2007 Conference

• New Forms Management Specialist

• New HSS Supervisor - Southern Team

• Access to Record

• BQA Numbered Memos August-October 2006

• Death Reporting for Hospitals

• Abandoned Cable Fire Hazard in Health Care Facilities

• Baseline Survey for Disaster Preparedness

• CMS Webcasts September-October 2006

• Latest CMS Survey & Certification Letters

• Administrative Rules Update

Bureau of Quality Assurance Becomes Office of Quality Assurance

The Department of Administration has approved the reorganization of DHS; thereby establishing the Office of Quality Assurance (OQA), formerly known as the Bureau of Quality Assurance (BQA). DHS requested the transfer of BQA from the Division of Disability and Elder Services (DDES), citing strong BQA management and removal of the perceived conflict of interest within DDES. The previous organizational structure included five regulated entities along with the regulating agency. DOA's approval allowed the transfer to occur effective October 15, 2006.

DDES and OQA will still share many strategic goals for quality improvement, regulatory flexibility, and person-centered services as DHS continues to reform the long-term care system and improve service in the mental health and substance abuse arena. The two agencies will continue to collaborate on these shared goals to ensure quality of life and quality of care and treatment for Wisconsin's vulnerable citizens. More thorough information about the transfer can be found in OQA memo 06-023 BQA, "Transfer and Name Change."

Updated OQA Senior Management Communication Information

As a reminder, 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 a member of the Office of Quality Assurance management team. This number will be highlighted in print communications and on OQA Internet pages.

Immediate response to, and resolution of your concerns is our goal. The number (608) 266-8481 will receive calls on a 24-hour basis, with voice mail set up to take messages when staff is not available to answer the phone. If an individual is not 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 appropriate OQA manager. The updated table (below) lists the OQA managers and the programs over which they have authority. If, however, your desire is to speak to the OQA Director or the Deputy Director, the table contains their telephone numbers and e-mail addresses.

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

Advancing Excellence for America's Nursing Homes Campaign

Beginning on September 29, 2006, nursing homes can voluntarily join the Advancing Excellence for American's Nursing Homes Campaign. The aim of this campaign is to seek excellence in the quality of life and quality of care for the more than 1.5 million American nursing home residents by enhancing choice, strengthening the workforce, and improving clinical outcomes.

This campaign was created by a broad-based coalition of organizations representing long-term care providers, caregivers, medical and quality improvement experts, government agencies, and consumers. Many quality improvement tools have been developed to assist providers' ongoing quality improvement efforts, and additional assistance will be provided by the Quality Improvement Organizations (QIOs), at no cost to providers. Providers that enroll in this campaign will voluntarily commit to publicly track their progress on at least three of eight measurable goals.

The following sources can be used to obtain additional information about this exciting opportunity:

• 9/11/06 CMS letter to Nursing Home Administrators   
• Campaign website at www.nhqualitycampaign.org
• Medicare Quality Improvement Community website at www.medqic.org 

CMS and OQA encourage providers to enroll in this campaign. Enrollment (or non-enrollment) in this campaign will have no impact on State survey and certification activities.

Recall of CoaguChek PT test strips

Roche Diagnostics and FDA informed consumers and healthcare professionals of the recall of CoaguChek PT test strips used to determine blood clotting time of patients taking anti-coagulant
medication to prevent blood clots. The recall was due to the potential for a test strip defect that may cause falsely elevated test results, resulting in an incorrect dose of anti-coagulant medication or unnecessary corrective measures being taken to reduce the effect of circulating anti-coagulants. Healthcare professionals who use CoaguChek PT test strips should institute "duplicate testing," or use two strips with different lot numbers on each patient to reduce the risk of bias. Home users of CoaguChek PT test strip should immediately discontinue use of the product and contact their healthcare provider.

Read the complete MedWatch 2006 safety summary, including a link to the FDA press release at: http://www.fda.gov/medwatch/safety/2006/safety06.htm#CoaguChek

FOCUS 2007

Save the Date:Mark your calendars for the FOCUS 2007 conference which will be held on August 8, 2007.  This conference is for staff from Adult Day Services, Assisted Living Facilities, Nursing Homes, Facilities Serving People with Developmental Disabilities and the Office of Quality Assurance.  The pre-conference date is August 7.  Watch for further details in the next Quarterly Update.

New Forms Management Specialist

The Office of Quality Assurance is pleased to announce the appointment of Rebecca (Becki) Slater-Reilly to the position of Records and Forms Management Specialist. Ms. Slater-Reilly's responsibilities will include coordinating OQA's response to all requests for survey files and related records made under state open records law, managing the Office's central files, developing and managing official forms and publications, and assisting with maintenance of the Office's web pages.

Ms. Slater-Reilly brings extensive skills and experience to her new position with OQA. She was the office manager and deputy in the Village of Oregon's Clerk/Treasurer's office since 2002, where she oversaw daily operations, served as records custodian, managed official village publications and legal notices, administered elections, and assisted with management of village finances. Prior to serving the Village of Oregon, she held similar positions with the Village of Cottage Grove, the Town of Madison, and Rock County.

Becki will be located in OQA's Central Office at 1 West Wilson Street in Madison. She can be reached by phone at 608-266-8368, and by email at SlateRA@DHS.state.wi.us.

New HSS Supervisor - Southern Team

We would like to welcome Mark Andrews as our new supervisor for the Southern Team of the Health Care Regulatory Unit in the Health Services Section. Mark has been with the Bureau since 2001. He served as an Adult Licensing/Certification Specialist prior to accepting his current position as Quality Assurance Program Specialist. Mark was a manager in the private sector prior to his State employment. He has a Bachelor of Arts degree with a major in Speech Communication and a minor in English. Mark began his new assignment on September 3, 2006 

Access to Records

With many providers transitioning to electronic records, we would like to provide some reminders about access to records. Facilities planning to implement an electronic records system, or those with an existing electronic records system, must ensure that the system meets the rules and regulations specific to its provider type. Additionally, each facility should have in place policies and/or a system that covers privacy and confidentiality issues, program oversight, designation of responsibility, legal and protective measures to foster data integrity, record reconstruction, and safeguards to prevent unauthorized access.

Surveyors' right to records is the same, whether records are kept in hard copy (paper) or electronically. If records are stored electronically, providers should have a process in place that allows the surveyor to readily access the resident/client/patient records in order to make compliance determinations. If you have questions specific to your provider type, please contact the OQA supervisor for your provider type. You can find this information at http://DHS.wisconsin.gov/rl_DSL/bqa.htm.

BQA Numbered Memos August-October 2006

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

Death Reporting for Hospitals

Hospitals are reminded that they are required to report to CMS any death that occurs while a patient is restrained or in seclusion for management of behavior, or where it is reasonable to assume that a patient's death is a result of restraint or seclusion used to manage violent behavior. The death must be reported to the CMS regional office prior to the close of business on the business day following the day of the patient's death. The CMS contact for Wisconsin hospitals is:

Justin C. Pak
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Division of Survey and Certification - Midwest Consortium
233 North Michigan Avenue, Suite 600
Chicago, Illinois 60601
(312) 353-0519 (phone) 
(312) 353-8053 (fax)

The link to the federal Survey and Certification Letter 06-31 is: www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp 

Abandoned Cable Fire Hazard in Health Care Facilities

Abandoned cable is a life safety issue, because certain types of cable contain highly combustible materials. Originally, the National Fire Protection Association (NFPA) code requirements, assumed a few cables installed in commercial structures would be safe. Today, NFPA estimates there is 60 billion feet of communication cabling installed in the United States. The evolution of cabling technology and the need for increasing bandwidth have resulted in the common practice of abandoning old cable.

NFPA, in an attempt to prevent a growing fire hazard, added requirements for the removal of abandoned cable in NFPA 70, the National Electrical Code section 800.52; which requires that accessible portions of abandoned cables for signaling, fire alarm, optical fiber, communications, CATV, and network-powered broadband communications be removed from buildings.

Example: New nurse call wiring is being installed. The old nurse call wiring would be removed

Baseline Survey for Disaster Preparedness

The State Expert Panel on Healthcare Facilities will soon be sending an announcement, via BQA Memo, regarding their work plan to assist healthcare facilities with their disaster preparedness plans. The first step in this work plan is a Web Cast, scheduled for Tuesday, November 8, 2006, on "Emergency Preparedness for Healthcare Facilities," facilitated by a member of the Expert Panel, Michael Berry, Administrator of Mount Carmel Nursing Home in Greenfield, Wisconsin. A Base-Line Survey will also be available on-line on November 8th to help identify the needs and priorities of all healthcare facilities in disaster preparedness.

CMS Webcasts September-October  2006

Listed below are the CMS webcasts that were produced between September and October, 2006. They will be available for one (1) year after the date of broadcast. You may access these webcasts at http://cms.internetstreaming.com/ .

9/15/06 - Secondary Prevention: Preventing Disabilities Through Chronic Disease Management

Latest CMS Survey & Certification Letters

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@DHS.state.wi.us. Please note that the CMS Internet site for all S & C memos is: www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp.

Administrative Rules Update

HFS 83 - "Community Based Residential Facilities"

The HFS 83 re-write 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. The re-write workgroup continues to meet with the advisory committee to review proposed revisions to the rule and to make changes, as necessary. For more information, you may view the Statement of Scope of proposed rules on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov/  (exit DHS).

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 and recognize the increase in the number of adults in need of guardianship and the increase in the complexity of their needs. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov/  (exit DHS).

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 web-site at http://adminrules.wisconsin.gov/  (exit DHS).

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 web-site at http://adminrules.wisconsin.gov/  (exit DHS).

HFS 132 - "Nursing Homes"

BQA 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 web-site at http://adminrules.wisconsin.gov/  (exit DHS).

HFS 133 - "Home Health Agencies"

The HFS 133 re-write 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 DHS Office of Legal Counsel. For more information, you may view the Statement of Scope on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov/  (exit DHS).

HFS 148 - "Cancer and Chronic Diseases Drug Repository Program"

Chapter HFS 148 has been amended to include prescription drugs and supplies for chronic disease, in addition to cancer drugs, in Wisconsin's drug repository program. The revised rule was published in the Wisconsin Administrative Register, and became effective August 1, 2006. For additional information, you may view the rule on the Wisconsin Administrative Rules web-site at http://adminrules.wisconsin.gov/  (exit DHS).

For additional information about Wisconsin's Drug Repository Program, you may view http://DHS.wisconsin.gov/bqaconsumer/cancerdrugreposy.htm 

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