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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 2020
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Contact Precautions and Enhanced Barrier Precautions
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In the
July 2019 newsletter
, we discussed multidrug-resistant organisms (MDRO) as they relate to long-term care (LTC) facilities. In addition, we also reviewed colonization versus infection and the possible implications for an LTC facility. This article will focus on Contact Precautions and Enhanced Barrier Precautions (EBP) recently introduced by the Centers for Disease Control and Prevention (CDC). Historically, Contact Precautions are burdensome in LTC facilities as the use of personal protective equipment (PPE) and room restriction to prevent transmission of MDROs can negatively impact residents’ quality of life. Enhanced Barrier Precautions have been developed by CDC to assist with decisions regarding PPE use and room restriction, with the goal of improving residents’ quality of life while also providing protection for other residents and staff. You can find the CDC document on Enhanced Barrier Precautions, “Implementation of Personal Protective Equipment in Nursing Homes to Prevent Spread of Novel or Targeted Multidrug-resistant Organisms (MDRO) ” released on July 26, 2019, at
https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
.
Case Study 1.
Mr. Jefferies is transferring back from the hospital with a leg wound that tested positive for a carbapenem-resistant Escherichia coli. Drainage from the wound is controlled by dressing. Mr. Jefferies has finished a 10-day course of antibiotics and is getting dressing changes two times per day.
Question 1.
What type of PPE would be required for high-contact situations such as dressing, bathing/showering, providing hygiene, changing linens, or wound care?
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FREE TRAINING OPPORTUNITIES
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LTC2Prepare – Emergency Preparedness 301: Catastrophic Planning
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Kentucky is Earthquake Country and it’s not just the New Madrid Fault in western Kentucky!
In January 2020, the U.S. Geological Survey reported a magnitude 3.8 earthquake struck near Fincastle, Tennessee and it was felt around East Tennessee and southern Kentucky. This earthquake occurred along the Eastern Tennessee Seismic Zone. Is your facility prepared?
Attend LTC2Prepare EP 301: Catastrophic Planning on March 24-25 in Louisville at the Parklands of Floyds Fork, or April 29-30 in Berea at Berea College.
Registration is FREE!
These conferences will focus on planning for Catastrophic Events such as earthquakes, extended power outages, flooding, etc. This content is new and different from the previous EP 101 and EP 201 conferences. Speakers from the Central U.S. Earthquake Consortium will speak and present the new
Kentucky LTC Mitigation Guide
which will assist facilities in preparing for all types of emergencies.
Topics to be discussed include:
- Tabletop Exercise Train-the Trainer Session - Flooding and Extended Power Outage
- KY Real World Catastrophic Risks
- Catastrophic Planning: How is it Different?
- Communication Planning and Technological Advances
- It’s Not If But When...Earthquakes Zones in Kentucky
- Protecting Yourself, Your Staff and Your Residents
- Facility Mitigation - What You Can Do to Lessen Damage
This program has been submitted for Continuing Education hours to NAB/NCERS for Nursing Home Administrators and this program has been submitted to the Kentucky Board of Nursing for Continuing Education credits through University of Louisville Hospital, provider number 4-0068-7-20-1141. These CE credits are FREE!
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FREE WEBINAR
"Co-Morbid Medical Illnesses as a Cause for Dementia & Decline"
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NEW TRAINING EVENT
Upcoming PAC QRP Requirements and FY 2020 Training Resources
The Centers for Medicare & Medicaid Services (CMS) is offering a quick web-based training to walk providers through upcoming changes to the Quality Reporting Programs (QRPs) for the following post-acute care settings along with an overview of existing and upcoming training activities designed to support providers in successfully complying with associated reporting requirements:
- Home Health
- Inpatient Rehabilitation Facility (IRF)
- Long-Term Care Hospital (LTCH)
- Skilled Nursing Facility (SNF)
This web-based training will:
- Demonstrate how the quality measures used in the Home Health, IRF, LTCH, and SNF QRPs tie to CMS’ Meaningful Measures Initiative;
- Provide a detailed list of data elements that have already been incorporated into the post-acute care QRPs along with those being implemented in the IRF, LTCH, and SNF care settings on October 1, 2020, and the Home Health care setting on January 1, 2021;
- Provide links to training resources to support providers in implementing existing reporting requirements associated with the QRPs; and
- Offer a preview of upcoming training activities to support the implementation of new reporting requirements, including dates, so that providers can begin to plan to incorporate these important training events into their busy schedules.
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If you have technical questions or feedback regarding the training, please email the PAC Training mailbox. Content-related questions should be submitted to the Quality Reporting Program Help Desk for your care setting.
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Updated Contact Information for iQIES Help Desk
Please see below for the updated email address for the iQIES Technical Help Desk:
Phone: 800-339-9313
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Kentucky Health Survey Registry (Annual Utilization Surveys)
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The Kentucky Annual Utilization Surveys are being released on January 30, 2020. The deadline has been extended to March 30, 2020. The delay is due to system and security upgrades. All licensed Long Term Care facilities and Home Health providers are required to report. These include Nursing Facility, Personal Care, Nursing Home, Alzheimer, Intermediate Care and ICF/IID beds. Additionally, MRI, PET, Megavoltage Radiation, Hospice, Hospital, Chemical Dependency and Psychiatric Residential Treatment Facility, services are required to report. Reporting of the data is required by 900 KAR 6:125.
Any request for an extension of the deadline must go through Elizabeth Tutt, Survey Administrator and Heatlhcare Data Analyst. You may contact her by email or by calling (502) 564-7940 Ext.3156. For survey completion go to
https://prdweb.chfs.ky.gov/OHPSurvey/
to submit data. The facility license number is the login and the facilities should create their own password the first time they log in each year.
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CMS Region IV LTC Quality Improvement Initiative
Use
Head to Toe Infection Prevention Toolkit
and the
Urinary Incontinence
Clinical Practice Guideline (CPG)
The newly released CMS
Head to Toe Infection Prevention Toolkit
is designed to help your facility reduce preventable infections, including pneumonia, skin infections, and UTIs. Use the AMDA Clinical Practice Guideline:
Urinary Incontinence
as a training tool for your staff.
Access the FREE exam and have Nurses, Social Workers and Dietitians/Nutritionists earn FREE CE hours. Other staff can earn Certificates of Completion.
Check out the other 19 Clinical Practice Guidelines as well as the other educational/training resources. Additional FREE CE exams for Nurses, Social Workers and Dietitians/Nutritionists as well as Certificates of Completion exams are available on the website,
www.cpgltc.org
.
For access to this password-protected website, contact the Help Desk at
help@cpgltc.org
.
This CMS Region IV LTC Quality Improvement Initiative is a collaboration between CMS Region IV, State Survey Agencies and the University of Louisville, Kent School of Social Work. Materials were produced pursuant to the Long Term Care (LTC) Quality Improvement Initiative/ AMDA Clinical Practice Guidelines and CMS Region IV Website: Sponsored by University of Louisville Research Foundation, Inc., Alabama Medicaid Agency; State of Florida, Agency for Health Care Administration; Georgia Department of Community Health, Grant #16051G; Kentucky Cabinet for Health and Family Services, Office of the Inspector General, Grant # PO2 723 1600004042 1; Mississippi State Department of Health, Mississippi Division of Medicaid in the Office of the Governor; and South Carolina Department of Health and Human Services. CMS Project Numbers: 2015-04-AL-UOL-0303; 2015-04-FL-UOL-0303; 2015-04-GA-UOL-0303; 2015-04-KY-UOL-0303; 2015-04-MS-UOL-0303; 2015-04-SC-UOL-0303.
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National Partnership for Dementia Care Update
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Each quarter interested supporters the CMS Atlanta region gather to share improvements with the antipsychotic medication use, best practices in dementia care, the great CMP funded work that is going on to support the residents of nursing homes who have dementia and more. The ‘late adopter’ data is also something that is discussed on each call and efforts to improve these rates are always good to learn. Many homes have identified the work of person centered care practices as key to anticipating the behavior changes of the residents, calming their reactions to care practices (ie. bathing) and facilitating better understanding of what residents are trying to tell the caregiver. Stability of the workforce is a huge influence in this effort. CMS continues to offer toolkits for this work. This past November a toolkit to improve staff satisfaction was released. Using these ideas can lead to staffing stability.
Be sure to join in the Medicare Learning Network on March 3
rd
to learn more about this priority - building a satisfied workforce in your nursing home.
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Dementia Care: CMS Toolkits Call — March 3
National Partnership to Improve Dementia Care and Quality Assurance Performance Improvement
Tuesday, March 3 from 1:30 to 3 pm ET
Register
for Medicare Learning Network events.
During this call, learn about new CMS toolkits for nursing homes:
- Head-to-Toe Infection Prevention: Easy to access best practices for direct care staff to prevent infections before they occur
- Developing a Restful Environment Action Manual: Non-pharmacological approach to improve the quality of life and quality of care for residents living with dementia
- Staffing Toolkits: Staff Competency Assessment, Employee Satisfaction Survey, and Guide to Improving Employee Satisfaction
Speakers: Cathleen Lawrence, Michele Laughman, Sheila Hanns, and Dara Graham from CMS.
Target Audience: Consumer and advocacy groups; nursing home providers; surveyor community; prescribers; professional associations; and other interested stakeholders.
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MDS 3.0 Item Set
A new DRAFT version of the MDS 3.0 Item Set Change History for October 2020 (v1.18.0) was posted. This document reflects the changes in the DRAFT version of the 2020 MDS item sets (v1.18.0) posted on December 20, 2019. The file is located in the Downloads section of the
MDS 3.0 Technical Information
site.
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MDS 3.0
QM User’s Manual Version 13.0 Now Available
The MDS 3.0 QM User’s Manual V13.0 and Quality Measure Reporting Module Table V1.8 have been posted. The MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. The MDS 3.0 QM User’s Manual V13.0 can be found in the Downloads section of the
Quality Measures
webpage and the MDS 3.0 QM User’s Manual V12.1 has been moved to the Quality Measures Archive
webpage
. The Quality Measure Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module, with a unique CMS identification number specified for each QM. The Quality Measure Reporting Module Table V1.8 can be found in the Downloads section of the
Quality Measures
webpage and the Quality Measure Reporting Module Table V1.7 has been moved to the Quality Measures Archive
webpage
.
Two files related to the MDS 3.0 QM User’s Manual have been posted:
- MDS 3.0 QM User’s Manual V13.0 contains detailed specifications for the MDS 3.0 quality measures. MDS 3.0 QM User’s Manual V13.0 is available under the Downloads section of the Quality Measures webpage. It is included in the zip file titled User Manuals - Updated 01-21-2020 (ZIP).
- Quality Measure Identification Number by CMS Reporting Module Table V1.8 documents CMS quality measures calculated using MDS 3.0 data and reported in a CMS reporting module. A unique CMS identification number is specified for each QM. The table is available under the Downloads section of the Quality Measures webpage.
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Fiscal Year (FY) 2021 and FY 2022 SNF QRP
Quick Reference Guides Available
Quick Reference Guides for FY2021 and FY2022 are now available in the Downloads section of the
SNF Quality Reporting Data Submission Deadlines webpage
. The Quick Reference Guides provide high-level information on the SNF Quality Reporting Program, including frequently asked questions and helpful links.
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New On Demand FFVR
The PBJ On Demand FFVR (Final File Validation Report) is now available to all PBJ Users. The report allows a User to re-generate PBJ Final File Validation Reports that are greater than 60 days old and have been purged from their facility’s CASPER folder. Full details and instructions to run the report can be found in the CASPER Reports Guide located at:
https://qtso.cms.gov/reference-manuals/tools
Updated PBJ FAQ’s
New XML File Layout: fileSpecVersion 4.00.0 (implement before June 2, 2020) A reminder that there is a revised version of the PBJ Data Specifications (Version 4.00.0) available to Users. The new release of the Data Specifications reconciles changes to the file layout, fileSpecVersion 4.00.0. Census tags have been removed from the 4.00.0 version due to CMS no longer collecting Census data from PBJ as of April, 2018. No immediate changes are needed when using the current PBJ Submission File fileSpecVersions (2.00.0 and 2.00.3), however, users are encouraged to begin using PBJ fileSpecVersion 4.00.0.
XML files submitted with versions other than 4.00.0 on or after June 2, 2020 will be rejected. Please note this does not apply to the PBJ Administration Submission File format. Users who use this file format for linking employees should continue to use fileSpecVersion 1.00.0.
There you will find the 4.00 Submission Specs, 4.00.0 XSD, and 4.00.0 Excel to XML Template.
The QIES Technical Support Office (QTSO) Help Desk is available for technical support and may be contacted by phone at 800-339-9313 or by email to
iqies@cms.hhs.gov.
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Publication of FY 2022 SNF Annual Payment
Update (APU) Overview Table
The SNF QRP Table for Reporting Assessment-Based Measures and SPADEs for the FY 2022 SNF QRP APU
is now available for download on the Skilled Nursing Facility (SNF) Quality Reporting Program Measures and Technical Information
webpage
. This table indicates the MDS data elements that are used in determining the APU minimum submission threshold for the FY 2022 SNF QRP determination.
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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
Chrystal Daugherty
MDS Assessment/Coding Issues
Rhonda Littleton-Roe
Transmission or Technical
502-564-7963 x.33
00 or
e-mail
Please note: 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.
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?
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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 Acting 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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QSEP: Quality, Safety & Education Portal
The Centers for Medicare & Medicaid Services (CMS) Quality, Safety & Oversight Group (QSOG) Quality, Safety & Education Division launched the Quality, Safety & Education Portal (QSEP) on January 6, 2020. QSEP is a replacement of the Integrated Surveyor Training Website (ISTW), providing a user-centered, self-service training portal that makes it easier than ever to take control of surveyor training via training plans and improved reporting.
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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
Vacant
Deputy Inspector General
Director
Assistant Director
Vacant
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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