|
Have a suggestion for a future topic? Click the link below and submit your suggestion.
|
| 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.
|
| 
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 |
| FIND AN OMBUDSMAN
|
The Kentucky LTC Ombudsman Program recently updated the LTC Ombudsman Directory. The directory includes contact information for each of the 15 districts.
|
|
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.
|
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
October 11 - 12, 2017
ADVANCED MDS TRAINING November 9, 2017
|
|
(More details will be available in forthcoming newsletters.)
|
|
Division of Health Care Leadership Team
Inspector General
Deputy Inspector General
Assistant Director
Assistant Director
Pharmacy Consultant
|
|
|
Long Term Care
Provider Newsletter
June
2017
|
Hello Everyone,
This month I just want to discuss a few "little things" that might be of interest to you. We often spend a great deal of time focusing on the bigger things, and can lose sight of the little ones.
First, your facility may have been the recent recipient of a recertification survey, revisit or complaint investigation survey that included a federal surveyor who was evaluating the performance of state agency surveyors. Our agency receives feedback from CMS about these surveys, and there were a few items of concern that the federal surveyors noticed on more than one occasion. I am passing them along to you and to our survey staff so that we can all be aware of these concerns:
- Facility staff were seen placing the domes which cover food trays, upside down on the residents' tables, and using them as trash receptacles, leaving them on the tables during the meal. This is considered a dignity issue.
- Residents who were on fluid restrictions were noted to have full pitchers of water at the bedside. This may or may not be an issue depending upon the resident's cognitive status, willingness to comply with fluid restrictions, the resident's wishes related to the fluid restriction, and perhaps other factors, but would certainly be cause for further investigation by the surveyors.
- Related to Kitchen and Food Services, crumbs were noted by the federal surveyors in drawers and on trays in the kitchen. So, keep an eye out for those pesky crumbs and don't let them get a foothold in your kitchen.
- During medication pass, the person administering liquid medications from a multi-dose bottle needs to be sure and measure the liquid at eye level and sitting on a solid surface (such as the top of the medication cart) to ensure the exact correct dosage is poured and administered. The surveyor observing the medication pass would also need to see the dosage in the cup while the cup is sitting on a level, solid surface and view it from eye-level after the staff person has completed pouring the dosage into the medicine cup.
Second, I would like to clarify something from a previous newsletter that I wrote regarding timeframes for reporting abuse, neglect, exploitation and misappropriation, as well as severe bodily injury. I have had several follow-up questions, so I guess my explanation was not as clear as I had hoped. This is the short and sweet version:
- All alleged abuse (verbal, mental, and physical) must be reported within two hours of becoming aware of the incident or allegation.
- All incidents of severe bodily injury must be reported within two hours of becoming aware of the injury.
- Suspected neglect, exploitation or misappropriation must be reported within 24 hours of becoming aware of the incident or allegation.
Please remember that you must also immediately report all suspected abuse, neglect, exploitation or misappropriation related to children or vulnerable adults to DCBS, in accordance with state law.
Third, please note the release of S & C Memo 17-30 dated 6-2-17, which was revised and re-released on 6-9-17 to include the provider types affected by this requirement. This S&C memo relates to Legionella Risk in Healthcare Facility Water Systems. The memo discusses some of the things a facility must monitor and provides a link to a helpful resource. Please read this memo, and ensure that Legionella prevention is addressed in your overall infection prevention and control program and related policies and procedures.
If you have managed to read this far, I have saved the best for last. I am happy to announce that Kentucky has completed all of its MDS-focused surveys for this year. Even better, CMS will not be having us conduct any MDS-focused surveys for the next year. So, good for us, even better for you!
Finally, I just want to take a moment and wish each of you a Happy 4th of July holiday. Stay safe, enjoy family and friends, and take a moment to reflect upon the meaning of this holiday. Thanks for all you do!
Sandra Houchen, Director
|
|
Personal Care Home Survey Process
|
|
Personal Care Home surveys are conducted every 7 to 15 months and are required to be unannounced by State law. Complaint investigations will be conducted when allegations of regulatory violations are received and are also required to be unannounced.
When the survey team (1 or more surveyors) enters your facility, they will ask for the person in charge; announce the purpose of the visit; and, provide the person in charge with a list of needed documents. During the survey or complaint investigation, the surveyors will need a place to work and review documents and resident records.
A tour of your facility will be conducted to observe environmental conditions, as well as observe and interact with the residents in your facility. Private interviews will also be conducted with some of the residents to determine if the facility is in compliance with resident rights' requirements and how the resident feels about the care and services being provided.
Staff will be interviewed throughout the survey or complaint investigation, as needed, to gather additional information about compliance with regulatory requirements, and to ascertain their knowledge and training regarding important issues such as abuse and neglect, safety procedures, etc.
Please feel free to provide the surveyors with any additional documentation or information you may have that might help to resolve an identified concern or issue about which the staff was asked. If you have questions about any aspect of the survey process or regulations, contact your regional OIG office or the central office, and we will make every effort to assist you.
Click Here to read specific information that will help you prepare for your next survey.
|
|
LSC - Keeping Safety First
|
|
Inspection of Patient Owned Electrical Equipment
CMS does not specify a specific process to use when inspecting electrical equipment owned by a patient. However, th
e
facility would be expected to maintain documentation of how the inspection was conducted to be able to demonstrate to the surveyor that the facility is in compliance with the regulatory requirement. The inspection may include looking for exposed or frayed wiring, missing ground plugs and proper operation of devices such as televisions, radios and computers.
|
|
Important PASRR Announcement
|
As a result of provider feedback received during the April 26, 2017 and May 24, 2017 PASRR Level I Trainings, the Department for Medicaid Services (DMS) and Behavioral Health, Developmental and Intellectual Disabilities (BHDID) has revised the January 2017, MAP 409 Level I PASRR form. This January 2017 version of the form will not go into effect on July 1, 2017.
Please plan to begin using the revised December 2016, MAP 4095 PASRR Significant Change/Discharge Data form on July 1, 2017.
Please continue to use the March 2007, Level I PASRR MAP 409 form until further guidance is provided by DMS in the form of a Provider Letter.
|
|
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:
|
QSource Hosts Monthly Conference Call
The Kentucky Nursing Home Monthly Update Call is being hosted by QSource and is open to all Kentucky nursing homes. The next call is on July 13, 2017 at 2:00pm EST. Participants MUST register to get the call-in information.
Click Here to register.
Topics of discussion include the following: Upcoming Care Transitions Community Meetings, CDiff Reporting and Reduction, Payment Based Journals, Composite Score Improvement, QAPI, CE Opportunities, Falls, Tuberculosis and Pressure Ulcers. |
|
REGISTER NOW!
OIG-DHC LTC PROVIDER TRAINING
|
"One Stop Dementia Shop"
The Office of Inspector General, Division of Health Care will offer a free educational opportunity for Long Term Care Providers to attend the
"One Stop Dementia Shop" training. This 2-day training will be offered in Lexington on August 14-15, 2017 and in Louisville on August 17-18, 2017.
The training will assist Long Term Care facilities in complying with the CMS regulation revisions and Kentucky LTC surveyors with the new CMS LTC survey process regarding residents with dementia effective November 28, 2017. The training will demonstrate how the brain is affected by the disease process of dementia, identifying and addressing behavioral systems in residents with dementia and providing appropriate activities to residents with dementia.
Click Here to view the training brochure for more details.
To register, please logon to the KY TRAIN website and search for Course ID: 1071502 (Lexington) or Course ID: 107512 (Louisville). You must have your own individual KY TRAIN account in order to register and receive credit for attending the training. If you do not have an existing KY TRAIN account, then you will need to create one.
Deadline for registration is August 1, 2017. You MUST be preregistered on KY TRAIN to attend.
|
| TRAINING CONTACT INFORMATION Please contact Melissa Richard or Jami Biggs at 502-564-7963 for assistance with KY TRAIN or for more details about any of our training opportunities. |
|
MDS/RAI UPDATES
|
Updated CASPER Reporting User's Guide
The updated CASPER Reporting User's Guide for MDS Providers is available on the following websites:
- Welcome to the CMS QIES Systems for Providers webpage
- The MDS 3.0 User Guides and Training Information page on the QTSO website
Includes the following updates:
- Updated Cover and Table of Contents
- Updated Section 1 - Introduction
- New Section 53 - SNF Quality Reporting Program
New Report Category and Report
|
|
MDS/RAI CONTACT INFORMATION
Jennifer Smith - MDS Assessment/Coding
Rhonda Littleton-Roe - Transmission or Technical
|
|
|
|
|
