Issue#04-2018 April 2018
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 

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

 

Policy and Memos  

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. 

Transfer/Discharge Hearing Appeals

Please  submit your requests for transfer/discharge hearing appeals to Acting Secretary Scott W. Brinkman, Cabinet for Health and Family Services, by emailing:

NURSING HOME COMPARE  

5stars
Click To Visit Website
 
March 2018

 Kentucky's Top 10 Citations for Nursing Homes

 

Health Care

 

 

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 
Employment Opportunities  

To search and apply for career opportunities with the Office of Inspector General, please visit the Career Opportunities System webpage by clicking below.

Career Opportunities System
MDS, EPOC, PBJ and Others Using Remote Access
O n March 17th, a CMS upgrade began on the Juniper Gateways and the c lient software currently used by the QIES user groups who remotely log into CMSNet for required reporting. If you have not already completed it, please read the  additional information  on how to prepare for this software upgrade. 

Division of Health Care Leadership Team
  
Inspector General 

Assistant Director
 
Assistant Director
  
Assistant Director
  
Pharmacy Consultant 

Long Term Care 
Provider Newsletter

April 2018
   
 

Hello Everyone,

            I hope this newsletter finds each of you experiencing purpose and meaning in your daily work. The jobs that you and your staff do are so very important to so many people, many of whom will never be able to tell you. So, I just wanted to remind you of that as you go about your work today.

            I have a couple of items for discussion to share with you today, and will also answer a few more questions we have received from previous trainings.

            First, there have been some Life Safety Code questions about 15 second versus 30 second delayed egress locking systems on doors. According to the NFPA Code 101 (2012 Edition), if your facility wishes to have a 30 second delayed egress instead of the routine 15 second delayed egress, the 30 second delayed egress must be approved by the authority having jurisdiction. In Kentucky, this authority would be the Kentucky State Fire Marshal's Office.

            If your facility has requested a 30 second delayed egress or has posted a 30 second delayed egress on an exit, it is quite possible our Life Safety Code surveyors will ask to see an approval letter from the Kentucky State Fire Marshal's Office, and may ask you questions regarding the reasons for this decision, to determine whether this decision was based on resident safety needs, BIMS scores, resident diagnoses, etc., versus lack of adequate numbers of staff.

         Second, we have received some questions from the Ombudsman's office about employees, wearing name badges that identify who they are and what their job title is in the facility. Just as a reminder or if you were not aware of this requirement, KRS 216B.170 requires that all licensed healthcare facilities shall require all persons, including students, who examine, observe, or treat a patient or a resident to wear identification that identifies, at a minimum, the person's first name, licensure credential and position title or department. The statute goes on to state that this identification should be of a size and type and appropriately displayed so that it could be easily detected and read. I just wanted to put this out there so you can remind your employees to wear their name badges in a place where they are visible to the residents/families.

            On that same note, our surveyors are required to wear identifying badges also. If someone comes to your facility and states they are there to conduct a survey or an investigation or any other official function, and they are not wearing a name badge, it is perfectly appropriate and recommended that you request to see their identification. If there is still any doubt as to the identity of the person, feel free to contact the OIG Branch Office manager for verification.
          
Sandra Houchen, Director
 
Serotonin Syndrome
In the State Operations Manual, the interpretive guidelines associated  with Unnecessary Drugs, F757 (483.45(c) - (e)) address the topic of  adverse drug consequences .   Serotonin Syndrome is one of several adverse drug reactions or interactions that is covered rather briefly in these guidelines.  Thus, this will be the first in a series of more in-depth articles that discuss some of the specific adverse drug consequences that pose a risk to residents of the long-term care community.

 
KY Hepatitis Connection Newsletter
April 2018 Edition

In the attached April 2018 edition of the "Kentucky Hepatitis Connections" newsletter, you will find information and updates related to registration for the 5th Kentucky Viral Hepatitis Conference, updates on the HAV outbreak in Kentucky, the latest hepatitis treatment updates and opportunities for hepatitis continuing professional education.

Many thanks to our partners for all of your hard work, dedication, and commitment in keeping our communities healthy and safe. Don't forget, May is Viral Hepatitis Awareness Month. Please share your awareness activities with us! 

As always, please feel free to forward, copy, and distribute this newsletter to other professional peers in your network. We hope you enjoy our April Newsletter!

Dr. Brawley
Kathy, Amanda & Deb

Residents' Rights Posters
The Office of Inspector General, Division of Health Care is in the process of mailing posters with State and Federal residents' rights to all Kentucky long-term care facilities. For those that would like the ability to make larger or additional copies, we have provided links to the posters below and on our website.

 
 
 
Informal Appeal of Survey Findings
 
Every Long Term Care provider has the right to both an informal and formal appeal process following receipt of a completed Form CMS-2567. There are two informal appeal processes: Informal Dispute Resolution (IDR) and  Independent IDR (IIDR) .

Interested in Serving on an IDR Panel?
Kentucky requires one member of the IDR panel to be "a person currently engaged in the provision of Long Term Care services who has no affiliation with the provider disputing a deficiency." Typically, a Long Term Care Administrator is on each IDR panel. There is no payment or travel reimbursement for an Administrator serving on a panel. Administrators will be rotated. If a Long Term Care Administrator is interested in serving on a panel, a confidentiality statement must be signed prior to the participation in the first IDR panel.

Please complete the Confidentiality Agreement and submit via email, fax, or mail to:
Buffy Stone, IDR/IIDR Coordinator
Office of Inspector General
908 W. Broadway, L&N Bldg. 10-W
Louisville, KY  40203
Fax: (502) 595-4540
 
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].
 
 
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: 


               
 
QTSO Website Address Changing
In compliance with CMS Standards, the QTSO website at  https://www.qtso.com was renamed and moved to https://qtso.cms.gov during the March 18, 2018, downtime.

No functionality changes within the website will be made, and you can continue to use it as normal. A redirect from www.qtso.com to the new .gov address will be in place temporarily after the migration to allow for support of older references; however, QTSO Website users should update any bookmarks/favorites to the https://qtso.cms.gov address.
 
TRAINING SECTION
LTC2Prepare Conferences
A special one-day emergency preparedness conference for Certified Nurse Aides and other direct care staff will be held on June 13, 2018 at Buckhorn Lake State Park. This one-day conference will enable direct care staff to learn their roles in the emergency preparedness plan and program for their facility. All staff are to be trained annually on the emergency preparedness plan. The direct care staff that attend can become part of the facility Preparedness Team!
 
Registration is FREE!

The LTC2Prepare Initiative announces the third and final Emergency Preparedness 101 Conference to be held August 1-2, 2018. The location will be Kentucky Dam Village, Gilbertsville, KY. Members of the LTC facility's leadership team and/or safety committee members are invited to attend. There is plenty of seating available!
 
Registration is FREE! The series of EP 101 conferences are setting the stage for the next level of emergency preparedness to be scheduled this fall.
 
 
 
 
MDS/RAI CONTACT INFORMATION

  Buffy Stone - MDS  Assessment/Coding
  502-595-4958 x.5019  or  e-mail 
    
Rhonda Littleton-Roe - Transmission or Technical
502-564-7963 x.3300 or  e-mail
 

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.