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Cabinet for Health & Family Services
Office of Inspector General
Division of Health Care
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Long Term Care Provider Newsletter
February 2021
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The Kentucky Office of Inspector General is committed to the protection of patients and residents of healthcare facilities from the spread of infectious disease. Regarding any coronavirus (COVID-19) concerns, you may refer to the following website for the most up-to-date news and information:
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A Message from the Inspector General
I want to thank everyone for their participation in the Long-Term Care Vaccination Program. We have exceeded many other states in percentage of residents and staff that have taken the vaccine, but we still need to encourage those that don’t have any contraindications to get vaccinated. It is imperative that we reach somewhere between 70 to 90 percent vaccinations to ensure herd immunity. I am hopeful as reluctant individuals see that there are very few adverse reactions with taking the vaccine that their reluctance will diminish and they will feel comfortable taking it. We understand there are issues around new staff and new residents having access to receive the vaccine and are hopeful that more stable versions of the vaccine will come on the market soon and allow for long-term care pharmacies to have inventory on hand and facilities will be able to administer it as needed. Please remain vigilant around infection control practices, vaccinations are not an exemption from these practices. There is a much brighter future on the near horizon, thank you for all that you have done during this dark time.
Adam Mather, Inspector General
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Kitchen Fires
by Chris White, OIG LSC Inspector
Proper maintenance, procedures, and training are key to preventing kitchen fires. NFPA 96 Standard Ventilation Control and Fire Protection of Commercial Cooking Operations (2011 Edition) provides a guide for the safe operation of Commercial Kitchens. Common causes of fires in kitchens include improper cleaning procedures allowing grease and combustibles to build up on and inside the stove area, failure to maintain ducts and vents, electrical wiring issues, gas leaks, and the failure to maintain equipment.
Fires can be compounded due to a failure to maintain and properly use the extinguisher systems such as ANSUL hoods and K Type portable fire extinguishers. Common Life Safety Code deficiencies include the failure to use the primary fire protection equipment prior to using a portable fire extinguisher. The primary equipment automatically dispenses fire suppression agents in the protected area in addition to turning off the gas along with activating the alarm system. K Type fire extinguishers are to be utilized as a secondary backup. Additionally regular inspections should be completed to ensure that the extinguisher nozzles are aimed at the cooking surface and not toward the back of the stove or blocked by objects. Nozzles are commonly moved as part of the cleaning process. Additional common deficiencies include the blocking of doors, obstructed access to exits, unmarked emergency exits, no placards or obstructed and unreadable placards for the K type portable fire extinguishers, the failure to maintain equipment, and the failure to follow established policies.
Required fire drills and training should occur to ensure that staff are knowable with the proper procedures should a fire occur. These trainings and drills should be documented and available for survey review. Maintenance and inspection schedules are available in NFPA 96.
NFPA 101 (2012 Edition)
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.
Reference: NFPA 96 Cooking Operations (2011 Edition)
10.2 Types of Equipment
10.2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguisher as secondary backup.
10.2.2 A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.
10.2.2.1 The language and wording for the placard shall be approved by the authority having jurisdiction.
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Updated Provider Demographic Data Process
CMS will be transitioning to a new data source for a provider’s demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities/Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Hospices). These demographic data include such items as the provider name, provider-mailing address, provider physical address, State, ZIP Code, etc. These provider demographic data are displayed on the Provider and Quality Measure reports generated from the Quality Improvement and Evaluation System (QIES) Certification and Survey Provider Enhanced Reports (CASPER) Reporting application for SNF/NF and Hospice providers and reports generated from Internet Quality Improvement and Evaluation System (iQIES) for HHA, IRF, and LTCH providers. Additionally these same demographic data are displayed on the public reporting websites such as the Provider Data Catalog (PDC).
Historically, provider demographic data have been maintained in the Automated Survey Processing Environment or ASPEN software; however, CMS will be transitioning to use the demographic information from Provider Enrollment, Chain and Ownership System (PECOS). While this transition is underway, a final date when all demographic data will be obtained from PECOS has not been identified. During this transition, all PAC providers will be responsible to ensure their latest demographic data are updated and available in both the ASPEN and PECOS systems.
A referencing document that outlines the steps each PAC provider should follow can be found on the QTSO website. Should you have questions regarding this updated process, please contact the iQIES help desk by email at iQIES@cms.hhs.gov or by phone at (800) 339-9313.
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Economic Stimulus and Residents
On December 29 the U.S. Dept. of Treasury announced that they had begun delivering a second round of Economic Impact Payments (EIP) to millions of Americans. Residents are included. According to the Treasury, this second round of EIPs will be distributed automatically, with no action required for eligible individuals. Residents may receive the $600 by auto deposit, check or debit card. Residents should not be forced to give the money to a long-term care facility. Many residents have purchased things like clothing, computers/tablets, food, personal furniture, etc., that they want or need.
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PDPM Grouper DLL Package Update and Revised Errata
An update to the PDPM Grouper DLL package was posted. This is NOT a change to the previously posted DLL file itself, just supporting information. The documentation file was updated, as there were NTA mapping changes not previously documented. Also, one file in the source code zip from the previous package, mdsgrouper,h, was not the latest version. The correct version is included in this updated package. NOTE: the DLL was compiled with the latest version of mdsgrouper.h in the previous package. Therefore, there is no change to the DLL file itself.
An updated errata (V3.00.7) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. The resolution to issue 17 in the previous errata was flawed, as the addition of edit -3963d prevented submission of IPA inactivations. Therefore, edit -3963d has been suspended for now, and will be revised in a future release.
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Kentucky's Top 10 Citations
for Nursing Homes
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Informal Appeal of Survey Findings
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.
Chrystal Daugherty, IDR/IIDR Coordinator
Office of Inspector General
116 Commerce Ave.
London, KY 40744
Fax: (606) 330-2054
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MDS/RAI CONTACT INFORMATION
For questions regarding MDS Assessment, Coding, Transmission or
Please do not send any identifiable patient information through e-mail. This includes patient names, SSNs, dates of birth, or any other data items considered identifiers or Protected Health Information (PHI) under HIPAA. Please redact any PHI prior to sending.
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Is your certified nursing facility signed up for ePOC? If so, be diligent about keeping your account and password up to date. All correspondence is handled in the ePOC system, including the plan of correction. Furthermore, if there is a change in administrator, it is incumbent upon the facility to update the system.
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 ePOC.Support@ky.gov or call Rhonda Littleton-Roe at 502-564-7963 x.3300.
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Have you notified your residents?
Click the link below to download and/or print the contact list for various agencies.
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Which Branch is Serving You?
To provide the highest level of service, the Division of Health Care operates through four regional offices. Knowing the appropriate Branch to contact with questions and concerns will ensure you receive maximum service in minimum time. Review links below for detailed information.
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CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.
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Transfer/Discharge Hearing Appeals
Please submit your requests for transfer/discharge hearing appeals to Secretary Eric C. Friedlander, Cabinet for Health and Family Services, by emailing:
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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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Quality, Safety & Education Portal
CMS's QSEP provides the full curriculum of surveyor training and guidance on health care facility regulations. All training is available on-demand on a top-notch self-service portal. 24/7 access means you have the freedom to learn what you want, where you want, when you want.
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Employment Opportunities
To search and apply for positions within the Office of Inspector General, please visit the Kentucky Personnel Cabinet's web page by clicking below.
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DHC Leadership Team:
Inspector General
Deputy Inspector General
Director
Assistant Director
Assistant Director
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Want to Sign Up for This Newsletter?
If you have received a copy of this newsletter from a friend or co-worker, you can click here and enter your information to join our mailing list, or contact MelissaD.Richard@ky.gov.
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Commonwealth of Kentucky | Office of Inspector General | 275 East Main St., Frankfort, KY 40621 |
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The Office of Inspector General is the regulatory and licensing agency for all health care, day care and long-term care facilities and child adoption/child-placing agencies in the commonwealth.
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