Issue#08-2017 August 2017
Office of Inspector General 
Division of Health Care
 
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Have You Notified Your Residents? 

 


Click the link below to download and/or print the contact list for various agencies. 

 

REQUIRED Agency Contact Information for Residents of LTC Facilities

 

Which Enforcement Branch is Serving You? 

 

To provide  the highest level of service, the Division of Health Care operates through four regional offices. Knowing the appropriate Enforcement Branch to contact with questions and concerns will ensure you receive maximum service in minimum time.  Review links below for detailed information.

 

Regional Map

 

Contact Information 

 

 

LTC Facility Self-Reported Incidents & Complaints

    

New email addresses have been established for all email communications regarding LTC Facility Self-Reported Incidents and for use by residents and the general public to report possible violations of regulatory requirements.  


Each DHC Enforcement Branch has an assigned email address to receive this information.   Review the map in the above article to determine the appropriate Enforcement Branch.  
Click Here for new email addresses and additional contact information. 

 

 

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CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.

 

Survey and Certification Letters  

 

Kentucky's Top 10 Citations for Nursing Homes

 

Health Care

 

Life Safety Code

 

 

NURSING HOME COMPARE

5stars
Click to Visit Website

 

FIND AN OMBUDSMAN

Click to Visit Website
The Kentucky LTC Ombudsman Program recently updated the LTC Ombudsman Directory.  The directory includes contact information for each of the 15 districts. 
Click Here to download.

Transfer/Discharge Hearing Appeals

Please  submit your requests for transfer/discharge hearing appeals to Secretary Glisson, Cabinet for Health and Family Services by emailing:


 

Surveyor Training Website

 

Enter Here

This CMS website provides training information to include the preceptor manual, the State Operations Manual and other documents.

 

As always, the survey and certification process is a collaborative effort between CMS and providers.  This website will allow providers the opportunity to take the same courses as surveyors.  

 

Division of Health Care Leadership Team
  
Inspector General 

Assistant Director
 
Assistant Director
  
Assistant Director
  
Pharmacy Consultant 

Long Term Care 
Provider Newsletter

August  2017
  
 

Hello Everyone,

I want to thank everyone who attended the One-Stop Dementia Shop training in Lexington or Louisville, and especially those facilities that were able to send a Certified Nursing Assistant.  We received many positive comments about the training, and I think the consensus was that facility staff left with many specific and concrete ideas for providing care to and interacting with residents who have dementia.  I know I really learned a lot, and had a great time.  The only change i would make is next time we need to have tissues at each table.  Those videos and stories brought many attendees to tears!  

The Division of Healthcare in OIG has all our manager/supervisor positions filled in our 4 branch offices throughout the state.  For those of you who may be new or just have not had occasion to speak with them yet, here they are: 

Enforcement Branch
Regional Program Manager
Assistant Regional Program Manager
Complaints Coordinator
Western
Kathy Perry  
Carol McIntosh
Cheryl White
Northern Sandra MacDonald
Amy Ames Dana Scruse
Southern  Alisia Dunn Kim Brock Keith Partin
Eastern Gae Vanlandingham Elizabeth Richards Marissia Izlar

I am excited that we have our full management team in place in all the branch offices.  They are all dedicated, hard-working staff, and I am certain that you will find them to be an important resource for you if you have questions or concerns or need assistance with something. 

As most of you are aware, the recent revisions to the LTC regulations included requirements about notifying residents regarding how to contact various agencies such as the State Survey Agency, Protection and Advocacy, Department for Community Based Services (DCBS), Medicaid Fraud and Control Unit and the LTC Ombudsman.  There were specific requirements that these notifications include email addresses for these agencies.

OIG has contacted each of these agencies to get their most current information, and some have developed new email boxes to receive reports from residents or the general public.  For your convenience and assistance, click here to download the updated listing of these various state agencies and their contact information that must be provided to residents.  In addition, this list will also be available on the OIG website. I hope this will be helpful to you in ensuring compliance with regulatory requirements.

Finally, I would like to ask you to please ensure that you notify OIG as soon as possible of a change in administrators or a change in their email addresses.  Many of you do an excellent job of letting us know when there are changes, but it is easy to get busy and sometimes this slips through the cracks.  It is very important for OIG to have current administrator names and email addresses so that important information can be sent to you quickly and to ensure that you receive things in a timely manner.  Please call (502) 564-7963 and ask to speak to one of the OIG-DHC analysts.

In closing, I just want to remind you that survey staff and managers will all be in training to learn the new LTC survey process the week of August 28th.  If you contact us, we will make every effort to get back to you as soon as possible, but please be patient.  Of course, if there is a true emergency in your facility please let administrative staff know, and they will ensure that a manager gets back to you right away.  Enjoy what's left of summer, because we have a busy and exciting fall season coming up!  
Sandra Houchen, Director
 
Infection Control

Anticipation is building for November 28, 2017...phase 2 of the LTC regulation changes.  Some of the changes we will see will be related to infection control.  Here is a brief overview of some of the changes related to infection control.    
 
The "old" infection control tag (F441) will be broken into four different tags (F880: Infection Prevention and Control, F881: Antibiotic Stewardship Program, F882: Infection Preventionist Qualifications/Role, and F883: Influenza and Pneumococcal Immunizations [the old F334]).  F880 has an added emphasis on a system for identifying and reporting infections and communicable diseases and is based upon the facility assessment (see new tag at F838).  F880 also specifies that facility policies and procedures must address surveillance and reporting, standard and transmission based precautions, and an annual review of the Infection Prevention and Control Program with updates as needed. 
 
F881 requires the facility to have an Antibiotic Stewardship Program.  What exactly is an antibiotic stewardship program?  Stewardship is the job of supervising or managing something.  If we want to be good stewards, then we want to take good care of the things we are responsible for.  Some research says that we could enter a "pre-antibiotic era" in the next few years if the rate of MDROs (multi-drug resistant organisms) continue to grow at the current rate and that antibiotic stewardship is very important to avoid that disaster.  The Infectious Diseases Society of America defines Antibiotic Stewardship as "...coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration."  An effective Antibiotic Stewardship program will require a team of individuals that are willing to coordinate to ensure antibiotics are used appropriately.  Key members of the team MAY include the infection preventionist, the physician/medical director, and the staff nurse.  Communication and collaboration is key for an effective Antibiotic Stewardship program.  

 
Skilled Nursing Facility Quality Reporting Program
Do you have questions about the Skilled Nursing Facility Quality Reporting Program (SNF QRP)?  Please take a moment and review these resources.
You may contact CMS with questions regarding the SNF QRP program by emailing: SNFQualityQuestions@cms.hhs.gov
 
A Message from the KY LTC Ombudsman Program
Transfer/Discharge Notices to the Ombudsman Program

CMS issued a Survey and Certification memo ( 17-27-NH ) on May 12, 2017, that provides clarification regarding copies of transfer and discharge notices to the Office of the State Long-Term Care Ombudsman.  These notices should be emailed to nhoa@ombuddy.org.   Read More 

 
A Message from Kentucky's QIN - QIO
 The Office of Inspector General is pleased to provide information from the CMS funded QSource and atom Alliance, the Quality Innovation Network (QIN) - Quality Improvement Organizations (QIOs) for Kentucky. 
 
Click link below  to read a message from 
Kentucky's QIN-QIO: 
    

               
Webinar - Creating a Culture of Safety
 
The atom Alliance nursing home team invites  you and your QAPI team to participate in Learning Session 1 of our Creating a Culture of Safety virtual webinar series on Thursday, August 10th, 2017, at 2 p.m. EST.

Click Here for more details.
* Attention Long Term Care Providers *
QIO Offers Valuable Training

The Office of Inspector General encourages you to read Kentucky's QIO announcement regarding several excellent training modules they have developed, which have been well-received by facilities for whom the QIO has provided training.  If your facility has received an Immediate Jeopardy level deficiency or has been selected as a Special Focus Facility, Kentucky's QIO can provide valuable and FREE assistance and training.  I can assure you that the QIO is not looking to report issues to OIG, but only wants to help your facility achieve compliance, so please do not hesitate to avail yourself of this opportunity when offered.  
Sandra Houchen 
 
TRAINING ANNOUNCEMENTS
Coming Soon - MDS Trainings

In collaboration with Myers and Stauffer LC, OIG-DHC is offering two free educational opportunities for LTC Providers this fall. The MDS 3.0 Basic and Advanced trainings will be held at the Four Points by Sheraton located in Lexington, KY.   

BASIC MDS TRAINING ADVANCED MDS TRAINING 
November 6-7, 2017 November 9, 2017

(More details will be available in forthcoming newsletters.)
 
MDS/RAI UPDATES

A new version (V2.01.1) of the MDS 3.0 Data Specifications was posted.  This version is scheduled to become effective October 1, 2017. This FINAL version incorporates the changes identified for the FINAL version (v1.15.0) of the MDS 3.0 item sets. Note that there have been no additional specification changes since Errata V2.01.1.  
MDS/RAI CONTACT INFORMATION
 
Jennifer Smith - MDS Assessment/Coding
502-564-7963, x3301 or  e-mail 
    
Rhonda Littleton-Roe - Transmission or Technical
502-564-7963, x3300 or  e-mail
 
Unbridled Spirit  
The Office of Inspector General is Kentucky's regulatory agency for licensing all health care, long-term care, day care and child adoption/placing facilities and agencies in the Commonwealth. 
  
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