Regulatory Issues & Quality Improvement

LeadingAge Wisconsin understands that state regulations play an important role in ensuring the highest quality of care for aging adults. When new regulations are implemented, we provide our members with timely updates and easy-to-follow interpretations to help with assessing public policy trends and implementing regulatory initiatives. We encourage you to use the resources below to stay informed about the latest regulatory issues and quality improvement initiatives in Wisconsin.

Hospital to LTC Transitions Pilot Proposal

CMS Releases Phase 3 Requirements of Participation (06/29/22)

• QSO-22-19-NH 
• Appendix PP Guidance to Surveyor for Long Term Care Facilities 
• SOM Chapter 5 - Complaint Procedures 
• SOM Exhibit 23 - ACTS Required Field 
• SOM Exhibit 358- Sample Form for Facility Reported Incidents 
• SOM Exhibit 359- Follow-up Investigation Report
• Psychosocial Outcome Severity Guide 
  
  

• DHS Contracts for LTC Study (06-17-22)
  
  
• NASEM Quality of Care in Nursing Homes Report (4-6-22)

• Letter to President Biden on Nursing Home Reform (03-11-22)
  
  
• Letter to LeadingAge Nursing Home Residents & Families
  
  
• Addressing Nursing Home Workforce, Access, Payment and Regulatory Issues (12-31-21)

• CMS & OSHA Issue Vaccine Mandates
  
  
• EMResource -- Nursing Home Request

• Nursing Home Regulatory Reform -- LeadingAge Wisconsin

• Changes in Demographics of Nursing Home Residents (1996-2022)
  
• Changes in Demographics of Nursing Home Residents (1996-2023)

• 2024 Q1 Top 10 Federal Nursing Home Citations
• 2024 Q1 Wisconsin Top 10 Federal Nursing Home Citations
• 2023 Nursing Home Survey Statistics
  
• 2021 Nursing Home Survey Statistics
  
• 2021 Q3 Stats
• 2021 Q1 Stats
  
  
• Changes in Demographics of Nursing Home Residents (1996-2021)
• 2020 Nursing Home Statistic

• 2022 Half-Year Statistics
• 2022 Q2 Top 10 Nursing Home Cites
• 2022 Q1 Top 10 Nursing Home Cites
  
• 2021 Top 10 Nursing Home Citations 
  
• 2021 Top 10 Nursing Home Citations by Region 
  
• 2021 Q3 Top 10 Nursing Home Cites
• 2021 Q2 Top 10 Nursing Home Cites
• 2021 Q1 Top 10 Nursing Home Cites
  
  
• Comments to DHS on the IDR Vendor—Seeking Fairness
  
  
• 2019 DQA SNF Statistics
• 2019 DQA SNF Top Ten
• LeadingAge Objects to CMS Hand Icon

• 2019 Q3 SNF Citing Statistics
• DHS Statement of Scope for Revisions to DHS 88 - Adult Family Home Code 
• Issues cited at F686 (Pressure injury care) in 2018
• Issues cited at F880 (Infection Prevention & Control) in 2018
• 2019 Q1 Citing Statistics
• 2019 Q1 Citing Statistics by DHS Region

• 2018 Nursing Home DQA Statistics
• 2018 DQA Top Ten Cites
• WI Nursing Home Residents- 1996-2018

• DQA Nursing Home Cites: IJ F-tags and IDR Stats (10 months)
• DQA Nursing Home Citing Data-- 2018 2nd Quarter
• DQATop 10 Cites/ F-tags-- 2018 2nd Quarter

• NHA-- Board Reporting Resolution

• Wisconsin Nursing Home Cites-- DQA April 2018
• Wisconsin Top Ten Federal Citations: 11/28/17 - 3/13/18
• National Advocacy-- CNA Training; Preserve Medicaid; and Financing Reform
• LeadingAge (National) Issue papers 

• Alzheimer's and Dementia Legislation-- March 2018
• AB 630: Dementia Specialist Certification and CNA Training (75 hours)

• Dementia Certification/CNA Training (AB 630) 

• 2017 DQA Nursing Home Citing Data with National Comparisons
• WI Nursing Home Resident Characteristics-- 1996-2017
• Top 10 Nursing Home Cites (2017, 11 Months) 
• New Survey Process-- DQA Cites 11/28/17 to 1/22/18

• 2018 Safe Resident Assistance Program-- Grant Application

• CMS Nursing Home Citing Data – Region V – FFS 2017
• LTC Survey Procedure Guide (New Survey Process, Nov. 28, 2017)
• F-Tag Crosswalk (old vs. new)--DQA
• CMS Critical Element Pathways
• Guidance-- Wander Guards and Restraints
• DQA Nursing Home Citing Data-- 2017 (9 Months)
• CMS Entrance Conference Worksheet
• CMS Matrix Instructions for Providers
• CMS Matrix--Excel Format
• Resident Choice and Mitigating Risk (Optional Form Supported by DQA)
• Clinical Resource Center-- New Tools & Resources

• Testimony in Support of AB 432 (CNA Training) 

• SNF Facility Assessment Tool
  
  
• PBJ Reporting Data- 2Q 2017
• DQA Nursing Home Cites-- IJ Cites and Actual Harm Below IJ (2017- 7 Months)
• US and WI NH Cites 2017 (6 months)
• DQA NH Cites: Top Ten/WI and Regions 

• CMS CMP Memo
• CMS CMP User's Guide
• CMS Delays Phase II CMP Enforcement 

• LeadingAge Wisconsin Advocates Seek LSC Innovations 
• Linking WI CNA Training to the Federal Standard
• Health Issues Forum-- June 14, 2017
• CMS Presentation on New Survey Process for November 28, 2017

• Federal Update-- May 8, 2017

• Federal Advocacy-- Mega-Rule & HCBS Waiver (Regulatory Reform) 

• SOM – Appendix PP Requirements of Participation – 03/08/17 Revision

• CMS Asked to Suspend Mega Rule--RoPs
• LeadingAge Comments on Mega-Rule Problems
• LeadingAge Action Alert: Suspend the Mega Rule

The following two documents were shared by Jacob Kubik, Administrator at Good Samaritan Society in Lodi, Wisconsin 

• Blank template of the facility risk assessment
• Example of what a completed facility risk assessment would look like (PDF)

• QAPI How-To Guide
• Resident Rights Poster Revised 12.21.2016
• Mega-Rule Phase 1--Project Management
• CMS Issues Mega-Rule S & C Letter/Appendix PP
• CMS -- Access to Mega Rule Training (Nov 18th)
• MCS Mega-Rule -- Phase I
• CMS Nursing Home Mega-Rule: Summary and Guidance for Providers 
• Mega Rule -- Side-by-Side Summary

• WHA Post Acute Care Work Group
• Wisconsin CNA Training Program Pass-Fail Rates
• 5-Star Rating System-- Overview
• WI DQA Nursing Home Citing Data-- CY 2016
• CMS – Calculating IJ CMP Amounts
• Regulatory Relief Request
• LeadingAge Outlook for LTC Under Trump Administration
• CMS Region V Meeting-- Summary

• DQA Nursing Home Cites-- 1st Q 2017
• CMS Nursing Home Citing Data--Region V--FFY 2016
• LTC Quality Dashboard and Metrics--LeadingAge
• DHS Dementia Crisis Unit Pilot Proposal
• CMS Sepsis -- December 7, 2016 Webinar
• Arbitration Decision
• DON Council--75 Hour CNA Training Requirement
• CNA Training Hours (States)
• LSC-- Fireplaces
• DQA Nursing Home Citing Data- 2016 (9 months)
• Nursing Home Mega-Rule: Updated Materials- October 2016
• CMS Issues Nursing Home Mega-Rule-- Sept/Oct 2016 
• CMS Federal Emergency Preparedness Regs-- Sept 2016
• 5 Star Changes-- Wisconsin & National 
• 5 Star Changes-- National/All States Data
• Prevention and Treatment of Pressure Ulcers: Quick Reference Guide
• DQA Nursing Home Citing Data - 2016 (6 months)
• Submit Comments on CMS VBP and Quality Rule-- Member Guidance
• LeadingAge PowerPoint on VBP and Quality Rule
• LeadingAge Summanry of VBP and Qulaity Rule
• Federal Rule--CMS VBP and Quality Regs
• CMS Life Safety Code Revisions-- May 4, 2016
• CMS Response to LeadingAge Payroll-Based Journal (PBJ) Concerns
• 2/16/16 LeadingAge Letter to CMS on Payroll-Based Journal (PBJ) Requirements
• DQA SNF Cites -- 1st Q 2016
• DQA Prevnar Alert
• DQA Winter Symposium Presentation-- March 2016
• DQA Nursing Home Citing Data-- 2015
• CBRF Plan Review Submittal Change Draft Dec. 2015
• Electronic Video Monitoring and Filiming in BAL Facilities
• Draft DQA Memo Safe Use of Oxygen - Use of Hair Dryers
• Tuberculosis Screening in Assisted Living Facilities
• CMS Region V Survey Data-- December 2015
• DQA Memo on Respiratory Illness Outbreak
• Comments on CMS Propsed SNF Rule-- October 2015
• LeadingAge Wisconsin-- Speaker's Task Force, Oct 2015
• Lakeview-- Speaker's Dementia Task Force, Oct 2015
• WI DQA SNF Citing Data-- 2015 (9 mo)
• LeadingAge Federal Update-- September 2015
• Member Comments on Proposed CMS Nursing Home Rule-- Sept 2015 (WORD Document)
• Member Comments on Proposed CMS Nursing Home Rule--Sept 2015
• Provider Memo in Opposition to Legislation Permitting a Flu Vaccine Exemption
• DQA SNF Cites-- 2015 (6 mo) with IJ Summaries
• CMS Proposes Massive Rewrite of the Nursing Home Code
• SNF Citing Data-- 2015 (first 6 months)
• DQA Waiver Letters--RN Screening for TB
• Top Ten 2015 IJ Citations/Summaries
• Nursing Home Regulatory Reform Proposal - March 2015 Update
• S&C Memo 15-26 NH: Nursing Home Compare "3.0"
• DQA CNA Training Data; 2012 - 2014
• F-Tags Updated--CMS 
• F-Tags at a Glance (Nursing Facilities)
• Federal Nursing Facility Enforcement Grid
• DQA Nursing Home Citing Data--CY 2014
• Safe Resident Assistance Endowment -- Equipment
• Reciprocity to the Wisconsin Nurse Aide Registry
• Influenza Memo: Long-Term Care Facilities
• S&C Memo 15-16: CMP Analytic Tool
• CMP Analytic Tool User's Guide
• DQA Falls Pilot Report
• DQA Otis Woods-- December 3, 2014
• CMS to Review MDS and Staffing Data
• Antipsychotic Medication Reductions 2014
• 2015-17 Legislative Agenda
• DQA Nursing Home Citing Data-- September 2014

• KEPRO replaces MetaStar (Medicare)

• Transitions of Care- September 10, 2014 Program

• Success Through Less- SE WI Alz. Assoc Report-- August 2014

• DQA Nursing Home Citing Data (6-7 month, 2014) 

•  Additional Information for 2014 District Congressional Visits 

• Antipsychotic Medications Use - State and National Trends (March 2014)
  
  
• Wisconsin NF's Antipsychotic Drug Use
  
  
• DHS Nursing Home IJ Citing Report - OIG May 2014
  
  
• DQA Nursing Home Citing Data - 2014

• DHS Dementia Standards and Training Timelines - May 2014

• DHS - Employment Opportunities for Person with a Disability

• Comparison - NFPA 2012 LSC & 2000 LSC and NFPA 99

• LeadingAge Wisconsin Member Issues SOD to DQA

• LeadingAge Wisconsin HI Forum - April 29, 2014 - Agenda & Packet (Revised April 14, 2014)

• Draft Dementia Standard (WORD Version) (Revised April 14, 2014)

• Proposed Nursing Home Regulatory Reform Proposals - March 2014

• CMS Federal Emergency Preparedness Proposed Rule - February 2014

• DQA Citing Statistics: January - December 2013

• Nursing Home Quality Assurance Project

• CMS Region V:The Top Ten LSC Citations & Hints to Avoid Them
  
  
• CMS Region V: Deficiencies, Remedies Imposed, Top Ten Citations/Hints to Avoid Them
  
  
• Cardiopulmonary Resuscitation (CPR) in Nursing Homes
  
  
• Antipsychotic Medication Use - State and National Trend (October 2013)
  
  
• Contingency Plans -- State Survey & Certification Activities in the Event of Federal Government Shutdown

• Log of CMS Responses Made to State Survey Agency Questions regarding the Federal Government Shutdown

• RAI User's Manual - Version 3.0, October 1, 2013
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• SB 251 - Support Nursing Home Drug Formulary
  
  
• SB 212 - Support CNA Bridge and Grandfathering (training hours)
  
  
• CMS CMP Analytic Tool & Guidance
  
  
• DQA Citing Statistics: January - June 2013
  
  
• Pharmacy Northern Region Update 2013 - DQA Doug Englebert, R.Ph.
  
  
• CMS Data on Nursing Use of Antipsychotic Medication Use
  
  
• Draft Nursing Home Formulary Legislation
  
  
• Associations Support Nursing Home Drug Formulary
  
  
• Clinical Care and Quality Improvement Forum - June 19, 2013:
  DQA Data Reports: Top Ten Cites 2013 YTD (4/30/13) and 2012 Survey Cites and Resident Data
  Otis Woods, DQA Administrator: DQA Updates and Issues  
  DQA Nursing Home Citing Data: January thru May 22, 2013