Issue#12-2017 December 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

 

Click Here  to find an Ombudsman.

 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 communications regarding LTC Facility Self-Reported Incidents and for use by residents and the general public to report possible violations of regulatory requirements. Click Here for the 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  

Transfer/Discharge Hearing Appeals

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

NURSING HOME COMPARE  
5stars
Click To Visit Website
 

 Kentucky's Top 10 Citations for Nursing Homes

 

Health Care

 

Life Safety Code

 

ISTW: Integrated Surveyor Training Website

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. 

Click to visit ISTW



Long Term Care 
Provider Newsletter

December  2017
   
 

Hello Everyone,

I hope that this newsletter finds everyone having a lovely holiday season.  As you know, our new LTC survey process began on November 28, 2017; however, this agency began conducting our first surveys under the new process during the week of December 4, 2017.  We have several surveys using the new process under our belts now, and feel it is going as well as could be expected with a brand new process using new computer equipment and software.  These first few surveys took a bit longer, generally speaking, than under the old process, but we are hoping this is due to lack of experience conducting this process using this equipment, and think that we will become faster at the process with additional practice and experience.

Numbers of deficiencies cited averaged 4-6 and ranged from no deficiencies (Congratulations!) to 10 deficiencies, so really nothing terribly unusual regarding numbers of tags cited.  Surveyors did have a bit of trouble with sharing data from tablet to tablet due to a corrupted flash drive and some other issues, but we were able to resolve them on-site with calls to our excellent central office ASPEN (software program used for federal SOD's) staff and training staff. 


Sandra Houchen, Director
 
Phase II Changes in the LTC Regulations
Effective November 28, 2017, significant revisions were implemented in  the State Operations Manual (SOM) Appendix PP for Phase II of the new LTC survey process. Previously, the SOM included a total of fifteen (15) such groupings; on November 28, 2017, the number of regulatory groupings expanded to twenty-one (21).

The purpose of this article is to provide the reader with a brief overview of some of the revisions which occurred on November 28th. Click here to read the highlights of revisions within the various groupings.  
 
Flu Outbreaks in Long Term Care Facilities

The Kentucky Immunization Program would like to share five attachments, which include forms and guidance to use during LTCF Influenza outbreaks.

The attachments include:
Thank you for your partnership in helping to prevent and control Influenza outbreaks in Long-Term Care Facilities and our communities.  
 
ePOC Accounts 

Is your facility signed up for ePOC? If so, 

be diligent about keeping your account and password up to date. Click here for the CMS security rules.


If your facility is not signed up, see the Account Setup instructions.


Not sure if your facility has any ePOC accounts or have other questions? E-mail [email protected].

 
Temporary Enforcement Delays and Other Changes
  • Temporary moratorium on imposing certain enforcement remedies for specific Phase 2 requirements...
  • Freeze Health Inspection Star Ratings...
  • Availability of Survey Findings...
  • Methodological Changes and Changes in Nursing Home Compare...
See the attached S&C Memorandum for further details.
 
New SNF QRP Quality Measure Reports Available

Effective December 19, 2017, two new user-requested Quality Measure reports will be available in the SNF Quality Reporting Program report category in the CASPER Reporting application.  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: 
    

               
 
TRAINING SECTION
Free Educational Resources for KY LTC Providers


The Office of Inspector General, Division of Health Care is pleased to share the following announcement  and postcard  from the CMS Region IV Long-Term Care Quality Improvement Initiative. 
 
 
MDS/RAI UPDATES

The new DRAFT version of the 2018 MDS item sets (V1.16.0) is posted. This version is scheduled to become effective October 1, 2018. The files are located in the Downloads section of the CMS website
CASPER Reporting User's Guide for MDS Providers
  • Information is available on the following websites:
    • Welcome to the CMS QIES Systems for Providers webpage
    • MDS 3.0 User Guides & Training Info page on the QTSO website
  • The guide includes the following updates:
    • Updated Cover and Table of Contents
    • Updated Section 13 - SNF Quality Reporting Program
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
 
Division of Health Care Leadership Team
  
Inspector General 

Assistant Director
 
Assistant Director
  
Assistant Director
  
Pharmacy Consultant 
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. 
  
If you would like more information, please  visit our website
  
If you have an idea for a future article, please contact   Melissa Richard.