Issue#03-2018 March 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  

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 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. 

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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


Division of Health Care Leadership Team
  
Inspector General 

Assistant Director
 
Assistant Director
  
Assistant Director
  
Pharmacy Consultant 

Long Term Care 
Provider Newsletter

March 2018
   
 

Hello Everyone,

I hope this article finds everyone well, and looking forward to spring. Hopefully, the rainy, snowy, and chilly days are almost behind us. I want to clarify a few questions that we have had about various topics during our training sessions in November 2017 regarding the Federal regulations and also provide an update on clarification received from CMS on Life Safety Code regulations for certified nursing facilities.

Let's start with the Life Safety Code clarification. We have received updated guidance from CMS regarding the storage of aerosols and other combustibles. We will not be citing the laboratory tag in the future related to storage of aerosols and combustibles, unless these items are stored inappropriately in a LABORATORY in a certified nursing facility.

A few cans of aerosols and other combustibles stored here and there about the facility to be provided for resident/staff use will not be considered an issue. The facility is considered the resident's home, and a normal home would have some cans of hairspray, shaving cream, deodorant, etc. stored in it. If you are storing VERY LARGE quantities of these items that may be considered hazardous in one storage room (room has to be larger than 50 square feet to be considered a storage room), that room must be sprinklered, and have a self-closing device on the door.

Sandra Houchen, Director
 
Detection of Clostridium Difficile in Healthcare Facilities
A Message from the Kentucky Department for Public Health
Healthcare-Associated Infection Prevention Program

Clostridium difficile (C. difficile) is a common  cause of healthcare-associated infections (HAIs) and was estimated to be responsible for approximately half a million infections in the United States during 2011. During this same time period, the Centers for Disease Control and Prevention (CDC) estimated that approximately 29,300 patients who developed C. difficile infections (CDIs) died within 30 days of the diagnosis and the number of first recurrences of CDI was approximately 83,000. 1 Due to the increasing prevalence and severity of CDIs across the nation, the CDC has targeted C. difficile surveillance as an important component of the Emerging Infections Programs (EIPP) 2 and encouraged long-term care facilities to engage in surveillance activities that promote appropriate clinical testing for CDIs. Read more...

Exhibit A - Clostridium difficile  Testing Algorithm

Submitted by
Lynn P. Roser, PhD, RN, CIC, FAPIC
and
Andrea Flinchum, MPH, BSN, RN, CIC 
 
MDS, EPOC, PBJ and Others Using Remote Access

O n March 17th, a CMS upgrade began on the Juniper Gateways and the Client 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.

 
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
Free Caregiver Training Opportunity

The Alzheimer's Association presents:
Dementia Care Training for Professional Caregivers
April 13, 2018

Working with people who have dementia is about more than redirection. It is about understanding and interacting with another human being. The Alzheimer's Association of Greater Kentucky and Southern Indiana has received a generous three-year gift to present a free one-day workshop to help professionals who encounter joys and challenges of caregiving every day identify stressors, decode verbal and behavioral messages, and connect with those they care for using methods that are both productive and rewarding.

Topics include:
Effective Communication Strategies
Intimacy, Sexuality, and Dementia
Understanding and Responding to Dementia-Related Behavior
Viewing of nationally acclaimed "Bathing without a Battle"

Engage in real life ideas that can be integrated into your work-flow.

Change the way you think about your job every day.
  • Check-in begins at 8:30 with close of day at 4:30. Programs are free and will include lunch and an Alzheimer's Association pin.
  • Any single residence or business sending five or more participants will receive a window cling for their entrance, identifying program participation.
  • Program site: Foundation for a Healthy Kentucky 1640 Lyndon Farm Court, Suite 100, Louisville, KY 40223.
  • Space is limited and registration is required. Registration closes April 9th. Register at alz.org/crf or call 800.272.3900. Be sure to include email in registration to be reached for pertinent day of information.
  • 7.3 Nursing and Social Work CE's offered through Baptist Health. 
The materials, views and opinions provided in this training are those of the Alzheimer's Association and do not necessarily reflect the official policy or position of the Office of Inspector General.
 
2018 Update in Gerontological Nursing Workshop
Most health care providers currently provide at least some care to older adults.  This 2 day workshop will offer critically important training to improve the quality of care for elders. It is comprehensive and could be used for certification preparation purposes.
 
Please see the attached flyer for further information and details!

The materials, views and opinions provided in this training are those of the UK College of Nursing and do not necessarily reflect the official policy or position of the Office of Inspector General.
 
 
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.