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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
September 2020
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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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Letter from the Inspector General
Dear Providers,
First, thank you for taking care of our most vulnerable citizens in what has been the most difficult time in many of our lives. I know there are additional challenges every day as we work together to mitigate the effects of COVID-19. The ability to change quickly and effectively continues to be what is needed to stop the spread of the coronavirus. It was only a few months ago that masking was optional and more of a healthcare protocol instead of a community expectation. This month marks six months that the Commonwealth of Kentucky has been dealing with the pandemic. As you look at the response that we have all mounted together, I hope that you share the same sentiment that I do: we are all working hard and with unending resolve to stop this siege, and there is no room for complacency.
As a reminder, recertification surveys were suspended initially at the start of the National State of Emergency, but they became effective again September 1, 2020. Additionally, Focused Infection Control (FIC) Surveys will continue. It is important to understand that while FIC surveys can point out systemic infection control issues, they rarely reveal every breach related to infection control. Infection control process improvement is essential, especially during a pandemic. FIC surveys provide a snapshot, and it is the provider’s responsibility to ensure regular education, screening, and audits continue to take place - regardless of the survey’s outcome.
As we continue to navigate in these uncharted waters, my hopes are that we do not forget to be pragmatic in our approach, that we remember who we serve, and that we consistently thank those who serve in direct caregiving and support roles each day. I wish all my best to those charged to your care, your staff, you - and the families of all three... stay safe and well during these trying times.
Adam Mather, Inspector General
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CMP Announces New Grant Opportunity for Visitation Aid Assistance
On September 17, 2020, CMS announced a Civil Money Penalty Nursing Home Visitation Aid Grant opportunity which is now available for all certified nursing facilities. This grant allows up to $3,000 per facility to purchase plexiglass or similar dividers and/or purchase or rent tents to aid in visitation for residents as a result of the state of emergency due to COVID-19. Detailed information about this grant and the application form can be found on our webpage.
If you any questions, or need additional information regarding the Nursing Home Visitation Aid Grant, please contact Gina Riddell, Grants Administrator, at gina.riddell@ky.gov or 502-564-2888 Ext. 3341.
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Changes to Regulatory Requirements for Personal Care Homes
A revised version of 902 KAR 20:036, Operation and services; personal care homes, became effective on July 29, 2020, after consideration by the Health, Welfare, and Family Services Committee meeting. There is a link to the revised regulation on the OIG website.
The amendment to the regulation makes the changes described below:
- It updates the definitions, removes obsolete language, and adds definitions of “qualified mental health professional” and “serious mental illness.”
- The amendment also adds a definition of a “specialized personal care home (SPCH).”
- An SPCH is defined as a personal care home that participates in the mental illness or intellectual disability (MI/ID) supplement program pursuant to 921 KAR 2:015 or otherwise serves residents in which thirty-five (35) percent or more of the resident population has a serious mental illness (SMI).
- The amendment requires each SPCH to develop and implement written transition procedures to ensure cooperation with an individual or entity that assists with transitioning residents with an SMI to a community living arrangement.
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It also requires the administrator of an SPCH and at least one (1) direct care staff member to complete the MI/ID training workshop established by 921 KAR 2:015, Section 14, no later than January 29, 2021, and every two (2) years thereafter. Those trainings are currently held at Central, Eastern, and Western State Hospitals. Contact Daniel.Alpiger@ky.gov at Central State, Sara.Lucas@uky.edu at Eastern State, or SusanE.Reynolds@ky.gov at Western State for more information.
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The regulation also requires completion of the SMI Screening Form linked here: https://chfs.ky.gov/agencies/os/oig/dhc/Documents/SMIScreeningForm.pdf for each new or returning resident at the time of admission, and it requires completion of the SMI Screening form for each current resident no later than October 29, 2020 (this requirement will apply to PCHs in addition to SPCHs) (completion of these forms will provide a count of how many residents have SMI, and therefore determine if the 35% threshold is met and the facility is an SPCH).
- It adds a cross-reference to 902 KAR 20:205 which establishes the tuberculosis screening requirements for employees of health facilities.
- The amendment requires a summary or a copy of the resident’s records to be provided to the resident and the resident’s guardian if the resident transitions to a community living setting.
- It clarifies requirements related to the destruction of expired or unused controlled substances that are destroyed on-site.
- It adds cross-references to pharmacy regulations for those PCHs and SPCHs that store and administer controlled and non-controlled substances.
- It requires an SPCH to collaborate with the agency or team that is working with residents transitioning to community living pursuant to 908 KAR 2:065 to offer basic instruction in ADLs and IADLs to each resident who is identified as working to transition. ADL and IADL skills training include instruction that is integrated into the normal rhythms of life.
- The amendment requires an SPCH to maintain monthly documentation of ADL and IADL skills instruction provided to, or made available to and refused by, residents who are transitioning to living independently in the community.
- Finally, it also adds language to clarify that an SPCH is not responsible for selecting which residents receive basic instruction in ADLs and IADLs nor is the PCH responsible for ensuring mastery of the skills.
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Nursing Home Recruitment - 12th Scope of Work CMS Contract
Your organization is now eligible for FREE services, resources, and support from Alliant Quality, the Medicare Quality Improvement Organization (QIO). SEE ATTACHED FLYER
In late August, CMS requested all QIO contractors to revisit their recruitment efforts with a new list of eligible nursing homes meeting the following criteria:
- Rural or small homes - or - One or two star homes - or - Serve vulnerable populations
The CMS list of eligible homes for recruitment is based on Nursing Home Compare findings.
Facilities MUST be confirmed by November 1, 2020.
Don’t delay!
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Updated Your Facility HVA Recently?
Each LTC facility must establish and maintain a preparedness plan that must be reviewed, and updated at least annually.
E Tag: E-0006 §483.73(a)(1): The emergency preparedness plan must do the following:
(1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents.
Visit www.ltc2prepare.org to use the Kentucky electronic HVA tool. It provides Kentucky LTC site-specific mapping to ensure the most comprehensive information for each individual facility’s plans based on actual hazard experience
Continue to use all the disaster preparedness resources on the website, including:
- Updates on COVID-19 from CMS, CDC and the Kentucky OIG
- Comprehensive emergency planning manual
- Access to training conferences
- Catastrophic Planning resources
Each administrator has a unique username and password for their facility. Contact help@ltc2prepare.org for assistance with your facility username and password.
LTC2Prepare Initiative is funded through CMS Grant #2017-04-KY-0808 and the Kentucky Office of the Inspector General, PON2 723 1800000928 1, through the University of Louisville, Kent School of Social Work.
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Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Updates
The Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is seeking input from the public as part of the measure development process. CMS has posted Draft Measure Specifications: SNF Healthcare-Associated Infections Requiring Hospitalizations for the SNF QRP (SNF HAI measure). This document contains conceptual and technical measure information and provides a link to the Final Technical Expert Panel Summary Report: Development of a Healthcare-Associated Infections Quality Measure for the SNF QRP for the public’s review. Please review both of these documents and give feedback via the email: SNFQualityQuestions@cms.hhs.gov.
CMS would also like to announce the SNF HAI measure will be a part of the Measures Under Consideration list later this year and it is our intention to present this measure for pre-rulemaking review at the Measure Applications Partnership Post-Acute Care/Long-Term Care Workgroup meeting in December. CMS will be providing Confidential Dry Run Reports to alert each SNF of their SNF HAI performance score based on these draft measure specifications in the coming weeks.
Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Measure Calculations
and Reporting User’s Manual V3.0.1
The SNF QRP Measure Calculations and Reporting User’s Manual Version 3.0.1 and associated risk adjustment appendix and Hierarchical Condition Category (HCC) crosswalks are now available on the SNF QRP Measures and Technical Information webpage.
SNF QRP COVID-19 PR Tip Sheet is Available
The SNF COVID-19 PR Tip Sheet is now available. The purpose of this Tip Sheet is to help providers understand CMS’ public reporting strategy for the PAC QRP in the midst of the COVID-19 public health emergency (PHE). This Tip Sheet explains the CMS strategy to account for CMS quality data, which were exempted from public reporting due to COVID-19, and the impact on CMS’ Skilled Nursing Facility (SNF) Compare website refreshes. Please navigate to the SNF QRP Training webpage to download this document.
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Kentucky- Regional Infection Prevention Program (K-RIPP)
The COVID-19 pandemic has highlighted many challenges that healthcare facilities face in preparing for and responding to highly communicable infectious diseases in our facility populations. An important strategy in bolstering infection control readiness is to evaluate the strength and capacity of existing infection prevention infrastructure and processes in healthcare settings. The Kentucky Department for Public Health is pleased to announce a new program made possible through federal grant funding, the Kentucky- Regional Infection Prevention Program (K-RIPP). This program and staff are an extension of the Healthcare-Associated Infection/Antibiotic Resistance (HAI/AR) Prevention Program in Frankfort, Kentucky.
K-RIPP is a new initiative supported by Epidemiology and Laboratory Capacity (ELC)/Centers for Disease Control and Prevention (CDC) grant supplements awarded to Kentucky in 2020. The state has been divided into 10 regions with an infection preventionist (IP) assigned to each region. The regional IP will provide infection prevention and control assistance to healthcare facilities, local health departments, and other regional public health staff, through education, training, assessment of processes and procedures, and other support. We are pleased to announce that eight of 10 regional positions are filled. Recruitment to fill the remaining positions is ongoing.
The regional IP staff will be additional resources for long-term care facilities and other vulnerable populations to increase preparedness for COVID-19 and other infectious diseases. This will be accomplished through infection control assessments conducted remotely or in-person, assistance with implementing evidence-based practices, and quality assurance and performance improvement (QAPI) activities. The regional IP staff can assist facilities with developing a plan to mitigate any gaps identified during assessments or by surveys performed by the Office of Inspector General. This program is voluntary and non-regulatory. Additionally, the HAI/AR Prevention Program staff in Frankfort are always available for consultation.
Ruth Belflower will be the coordinator for these activities and can be reached at 502-991-1712 or Ruth.Belflower@ky.gov. You may also reach out to me, Andrea Flinchum, manager of the HAI/AR Prevention Program with questions at Andrea.Flinchum@ky.gov. The regional staff will be contacting you soon to make introductions. We appreciate your ongoing work to deliver excellent healthcare in Kentucky.
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MDS 3.0 Technical Information
jRAVEN
jRAVEN v1.7.4 is now available for download under the Downloads section of the MDS 3.0 Technical Information webpage. Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.7.4.
jRAVEN v1.7.4 includes the following enhancements:
- Changes in support of the MDS Item Set V1.17.2 and Data Specifications Errata V3.00.5
- The new MDS VUT, V3.4.0, also updated in support of the Errata V3.00.5
- The new PDPM Grouper, V1.0006, updated to include the new ICD Code Tables
PDPM Grouper, V1.0006
The FINAL version of the PDPM Grouper DLL V1.0006 has been posted, along with its source code and test cases. This version supports the calculation of PDPM payment codes on OBRA assessments when not combined with the 5-day SNF PPS assessment, specifically the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets. Note that the grouper will return 4-character codes for these OBRAs.
It is important to include the control item STATE_PDPM_OBRA_CD (as defined in the V3.00.5 errata for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications) for assessments with target date on or after October 1, 2020.
Note that this FINAL version supports the ICD-10 codes that are defined in the data specifications as valid for item I0020B for FY2021. Also, please note that the grouper expects valid FY2021 ICD-10 codes for I8000A-J when processing assessments with target date on or after October 1, 2020.
In addition, the lookup files containing the allowable ICD codes for item I0020B have been updated for FY2021, and is posted as a separate ZIP file. The file is located in the Downloads section of the MDS 3.0 Technical Information webpage.
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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
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.
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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