Nursing Homes: Forms, Memos and Publications

This page includes forms and other helpful resources related to nursing homes. Publications are files or websites with additional information. Division of Quality Assurance (DQA) numbered memos are documents that deal with:

Nursing home policies.
Guidelines for nursing homes managed by DQA.
Information and interpretation of federal and state regulations.

Questions? Email dhswebmaildqa@dhs.wisconsin.gov.

Forms

If a nursing home resident needs a psychotropic medication, guidelines must be followed to get informed consent. Learn more:

Find forms at Informed Consent for Medications F-24277 Series.

Preadmission screen and resident review

If a person being admitted may have a serious mental illness or developmental disability, a special screening is required. The preadmission Level II Screen must be completed before admission. In some cases, a short-term exemption may be granted.

Preadmission Screen and Resident Review: Level 1 Screen, F-22191

Publications

Avoiding Physical Restraints, P-63113 (PDF)
Consumer Guide: Consumer Information Reports for Nursing Homes and Facilities for People with Developmental Disabilities - Access consumer reports, resources, directories, survey results, and more.
Consumer Guide to Health Care: Finding and Choosing a Nursing Home - Find directories and survey results.
Hospice – Nursing Home Interface, P-00252 (PDF)
Independent Informal Dispute Resolution for Federally Certified Nursing Homes, P-01855 (PDF)
Informal Dispute Resolution for Nursing Homes and Facilities Serving People With Developmental Disabilities (FDD), P-01856 (PDF)
Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual - From the CMS (Centers for Medicare & Medicaid Services) website.
Pharmacy Newscapsule - Newsletter published regularly by DQA.
Resident Relocation Manual, P-01440
Role of Non-Certified Staff in Provision of Care, P-01559 (PDF)
Survey Guide for Long Term Care Facilities, P-62014 (PDF)

Memos

Memos from the Wisconsin Department of Health Services (DHS)

View our Memos Library to access a wealth of communications issued by DHS regarding policies and procedures and how they should be put into action.

DQA numbered memos

Select a link to view the memo. You can also view the list of all DQA Memos.

For an official paper copy of any numbered memo, email or write:

Email dhswebmaildqa@dhs.wisconsin.gov.
Mailing address:

Administrator’s Office

Division of Quality Assurance

PO Box 2969

Madison, WI 53701

Official Number	Description	Issue Date	Obsolete date
21-006	Wisconsin Administrative Code s. DHS 132.42 (3) (a) Pre-employment Screening for Clinically Apparent Communicable Disease	November 15, 2021
21-004	DHS Requests Nursing Homes Join Hospitals in Wisconsin to Use the EMResource Bed Tracking System for Health Care Entities	September 15, 2021
21-002	Notice and Requirements for Submitting Four-Year Renewal of Licensee Background Check Information	February 22, 2021
20-004	Wisconsin Nursing Homes – CMS 1135 Waiver Provisions and Governor Evers Executive Order # 21	June 8, 2020
20-008	State Licensure Application for Temporary Nursing Facility Expansion Units and Transfer Options during the COVID-19 Public Health Emergency	May 1, 2020
17-004	Notice of Mandatory Requirement to Submit Four-Year Renewal of Licensee Background Check Information	February 20, 2017
17-003	Fire Watch, Fire Plan, and Fire Reporting Update	February 17, 2017
16-008	Centralized Reporting of Client/Patient/Resident Death Determination	June 27, 2016	December 31, 2022
16-004	Guidance Reminder Regarding Handheld Devices and the Potential Misuse of Such Devices	February 23, 2016	December 31, 2022
16-003	Reminder Nurse Aide Eligibility Requirements	February 16, 2016	February 1, 2019