DQA & Nursing Home Provider Community Quarterly Meeting Recap
WHCA/WiCAL staff recently joined Division of Quality Assurance (DQA) staff and other representatives from the nursing home provider community for our quarterly meeting, an opportunity to receive updates from DQA and ask for answers on specific issues impacting WHCA/WiCAL nursing home members.
At our recent meeting, we received the following updates, primarily from Jessica Radtke and Juli Brandt with the Bureau of Nursing Home Resident Care (BNHRC):
BNHRC Staffing:
Amy Hambrecht has been hired as the new Northwestern Region RFOD, and Meaghan Baker is the new Southern Region RFOD. In addition, since both Amy and Meaghan were their region’s RFOS, BHNRC will now be hiring to fill the RFOS position in these regions. In addition, the Bureau has been working to fill open surveyor positions, so providers should expect to see trainees out on survey in the near future.
Pilot Projects:
Edocs was launched as a pilot program in the Northeast region to allow the electronic uploading of documents during the survey process instead of providing paper copies, according to BHNRC, feedback from providers has been positive and they will be expanding the program to another region soon. Keep an eye out for more details on when and where it will be expanded.
ePOC allows for direct communication electronically regarding plans of correction as part of the iQIES system. This system has come as a result of CMS’ transition to iQIES last July, and Wisconsin will trial the ePOC system in 1 region, most likely the Southern Region and will likely be rolled out in April. So far 300 providers have signed up and an expressed an interest in the new system, however not every provider has finished Step 2 of the registration, which is requesting administrative roles for the provider. Keep an eye out for updates on when and where ePOC is launched and make sure you have completed your registration for the system.
Changes to Ch. 5 & Ch. 7 of the SOM
DQA noted that most of the changes to Ch. 5 & Ch. 7 of the SOM made via QSO-26-03-NH, are already standard practice in Wisconsin. However, there will be some changes for providers and surveyors as a result of the changes relating to when surveyors can enter, that surveyors can’t skip days, the hours for early morning and evening surveys, and the requirement that surveyors spend 5 consecutive hours in a facility. These changes will impact the scheduling of surveys and what day/times surveyors enter your buildings.
In addition, since this meeting, providers have reached out to WHCA/WiCAL staff regarding an interpretation issue from DQA on the survey timeframes in the changes to Ch. 7. It is DQA’s current assertion that when a survey goes on for more than 4 consecutive days, the survey must be discarded and started over again. We have reached out to AHCA/NCAL regarding this issue, and it is our understanding that at least 1 other state has the same interpretation on the survey timeframes, the team at AHCA/NCAL are reaching out to CMS for clarification and more information on this issue. We will provide a follow up on this issue in the coming editions of Care Connection.
Risk-Based Surveys:
Wisconsin has been chosen by CMS to pilot a risk-based survey process. CMS has determined the set of criteria which makes a facility eligible for the risk-based survey process, these criteria have not been shared with WHCA/WiCAL nor DQA. DQA has received a list of eligible nursing homes and the first risk-based surveys should have occurred at the end of March. We understand that facilities that will be eligible to participate a “risk-based” or condensed survey will be facilities that have consistently positive survey outcomes (ie: No G or higher level deficiencies in the past 2 or more recertifcation cycles, 4-5 star rating, etc.)
What to expect from this pilot? Any eligible facility which has not already received their recertification survey will receive the risk-based survey. Those receiving these surveys should see a 2 day survey with 1-2 surveyors depending on the census of the facility.
Nursing Home Administrator and Director of Nursing Turnover:
As of the beginning of 2026 we have seen 59 changes in NHAs at nursing homes in Wisconsin, with 37 acting administrators currently in those roles. Additionally, we have seen 79 DON changes.
We will continue to track the changes in NHAs and DONs at Wisconsin nursing home facilities, as a crucial metric on the impact of our survey environment on facility staff. Additionally, if you are an acting administrator or you have an acting administrator in your facility who is seeking licensure as a NHA with the Department of Safety and Professional Services (DSPS), please reach out to Eric if we can help you through the licensure process.
Office of Plan Review and Inspections (OPRI) Life Safety Code (LSC) Surveyors:
The Office of Plan Review and Inspections currently has a large backlog of plans in review and a backlog of inspections. As a result, OPRI is contracting with Healthcare Management Solutions (HMS) to bring on contract surveyors to perform LSC surveys in March and likely April, conducting these surveys for more than 30 facilities. If you run into issues with these contract LSC surveyors please let Rick or Eric know so that we can be helpful in advocating for you.
UW-Oshkosh Past Non-Compliance Workshop:
DQA has worked with the team at the University of Wisconsin-Oshkosh’ Center for Community Development, Engagement and Training (CCDET) on a new training program on Past Non-Compliance.
There are two instances of this training already scheduled:
- Monday, May 11th – 12:30-4:30pm – In Person (Madison)
- Monday, May 18th – 8:30am-12:30pm – Virtual
For all upcoming training program opportunities visit the CCDET website.
