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Have a suggestion for a future topic? Click the link below and submit your suggestion.
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| 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 |
| FIND AN OMBUDSMAN
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The Kentucky LTC Ombudsman Program recently updated the LTC Ombudsman Directory. The directory includes contact information for each of the 15 districts.
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Transfer/Discharge Hearing Appeals
Please
submit your requests for transfer/discharge hearing appeals to Secretary Glisson, Cabinet for Health and Family Services by emailing:
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| Surveyor Training Website
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Enter Here
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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.
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Division of Health Care Leadership Team
Inspector General
Deputy Inspector General
Assistant Director
Assistant Director
Pharmacy Consultant
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Long Term Care
Provider Newsletter
July
2017
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Hello Everyone,
I hope you all had a great Independence Day holiday, and that everyone is rested and refreshed. As you know, there is LOTS happening in August through November that will keep everyone extremely busy.
First, we have the two-day dementia training in August (2 sessions) that the surveyors and management staff will be attending, and we look forward to seeing many of you there. Also, we have eight staff attending CMS's Train the Trainer session on the new LTC survey process, which will be going on for a week in Annapolis, MD, beginning on 7-31-17. When they return, they will begin training the surveyors on the new process. CMS is also holding week-long live webinars in August and September for surveyors on the new LTC survey process. After our staff have learned the process and are reasonably comfortable with it, we will look at trying to offer some training to providers on the new process.
To add to the busyness of this last part of 2017, Emergency Preparedness regulations have come out in Appendix Z of the State Operations Manual and will be in effect in November, 2017. There is a group in Kentucky working on training for LTC providers and surveyors on Emergency Preparedness, and we are hoping that training will be approved very soon and available to assist you with your Emergency Preparedness preparations. If you haven't had time, please take a little time to read Appendix Z. Since it covers all certified provider types, it can be a little confusing, so you need to spend some time with it, to see what applies to your level of care.
Finally, CMS has revised Civil Money Penalties (CMP's) and the CMP Analytic Tool. Survey & Certification memo S&C: 17-37-NH describes these revisions in great detail. These revisions came about in an attempt to increase national consistency in imposition of CMP's, and, while I am sure, providers would prefer no CMPs at all, these changes are welcome in establishing consistency and increased fairness in amounts of CMPs imposed and situations for which CMPs should be imposed. Some highlights of the changes are:
- Per instance CMPs will be used for past non-compliance where something occurred prior to the survey, but the provider has completely corrected it and is back in compliance prior to the start of the survey.
- A per instance CMP will generally be imposed for non-compliance that began before the survey and has not been corrected at the time of the survey. However, a per day CMP will still be used when a resident suffers actual serious harm at the Immediate Jeopardy level, when a resident has been abused, or if the facility has persistent deficient practices. This change will help to alleviate extremely large CMPs, in many cases, that would have accrued per day back to the date the non-compliance began. As you know, this could often be several weeks or more prior to the survey that identified the non-compliance, and would often result in very large CMPs even if there was no actual harm.
- Per day CMPs will generally be used where the non-compliance is found to exist during the survey and beyond, with some exceptions to allow a per instance CMP for facilities with good compliance histories, and where a single isolated incident causes harm to a resident, unless abuse has been cited.
- CMS Central Office in Baltimore will review all CMPs of $250,000 or greater.
Attached to this survey and certification memo, you will find the CMP Analytic tool. If you wonder how CMS determines CMP amounts for imposition, this tool is quite detailed and has been updated to reflect the new guidance. It describes base amounts for specific scopes/severities, as well as other factors that CMS must consider. I encourage you to take a few minutes and decipher the process, as it will help you understand possible outcomes from your survey and more about a process that affects all certified nursing facilities.
We look forward to seeing you at future training sessions, as we all learn together.
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Important information for
ePOC and MDS Submission Accounts
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All Certified Long Term Care facility employees who have QIES accounts
(ePOC or MDS) need to review the CMS policy below. Please keep your accounts active by resetting your password each time you are notified by QIES, so that you don't run the risk of having your ePOC or MDS accounts disabled or deleted.
QIES Security Notice: Disabling and Deleting Accounts
To better secure our applications, QIES security will require each user to successfully login every 60 days, effective June 26, 2017. If this does not occur, the account will be disabled and can only be re-enabled by contacting the QTSO
Help Desk at (800) 339-9313.
Accounts that have no activity for more than 365 days will be deleted. Once your account is deleted, you will not be able to use or re-enable the account. If your account is deleted, you will need to request access through CMS as you did originally; you will be assigned a new User ID and password when the access is granted.
QIES
users will continue to use QIES User Maintenance Application to update passwords as required every 60 days; and use security questions to unlock accounts if the password is forgotten or the account is locked due to the password being entered incorrectly three times.
If you have any questions concerning this information, please contact the QTSO Help Desk at
(800) 339-9313.
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A Message from the KY LTC Ombudsman Program
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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
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A Message from Kentucky's QIN - QIO
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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:
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| 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.
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* Attention Long Term Care Providers *
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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
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REGISTER NOW!
OIG-DHC LTC PROVIDER TRAINING
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"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, you will need to create one.
Registration closes on August 1, 2017, for the Lexington offering.
The registration deadline for the Louisville offering has been extended to August 13, 2017.
You MUST be preregistered on KY TRAIN to attend.
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Coming Soon - MDS Trainings
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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 |
| October 11 - 12, 2017 |
November 9, 2017 |
(More details will be available in forthcoming newsletters.)
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| 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. |
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MDS/RAI UPDATES
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Payroll Based Journal (PBJ)
The "PBJ Policy Manual (V2.3) 4-17-17" and "PBJ Policy Manual FAQ 4-17-17" have been updated to reflect changes to the submission guidelines. They are both available for download on the CMS website
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MDS/RAI CONTACT INFORMATION
Jennifer Smith - MDS Assessment/Coding
Rhonda Littleton-Roe - Transmission or Technical
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