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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
January 2020
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OIG Welcomes New Inspector General
Adam Mather was appointed the agency’s Inspector General effective December 30, 2019. Prior to joining CHFS, Mather worked with several long-term care companies based out of Louisville. He is a graduate of Louisville’s Ballard High School where he played football. He received a Bachelor of Science in Nursing from Georgia State University and currently holds a registered nurse (RN) license. He will be attending Cornell University this spring to work on a Master of Health Administration degree.
Mather said he wants to ensure public confidence in his office. "I am excited to take over the role as the Inspector General for the Cabinet of Health and Family Services. I look forward to working with the Long Term Care Community to ensure great patient care. I will be working closely with our team at OIG to ensure professionalism, consistency, and transparency."
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Recommendations from the 2019 Alzheimer’s and Dementia
Workforce Assessment Task Force
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Last year, Senator Robby Mills and Representative Deanna Frazier co-chaired the Alzheimer’s and Dementia Workforce Assessment Task Force during the 2019 interim. The task force met six times and heard from various stakeholders on a number of topics, including the current state of long-term care services, workforce shortages, retention issues, and innovative solutions that other states have implemented to recruit and retain staff.
Based on testimony presented by stakeholders, the task force submitted a report dated November 19, 2019, to the Legislative Research Commission with several findings, strategies, and recommendations for consideration and possible implementation. A copy of the report may be downloaded
HERE
.
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LTC2Prepare
– Emergency Preparedness 301: Catastrophic Planning
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The last two LTC2Prepare conferences,
EP 301: Catastrophic Planning
, will be held: March 24-25 at the Parklands at Floyds Fork, Louisville and April 29-30 at Berea College, Berea.
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
.
Your facility may be prepared for “small” emergencies, but are you prepared a “The Big One”? 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
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SNF Provider Threshold Report FY 2022
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The Skilled Nursing Facility (SNF) Provider Threshold Report (PTR) for Fiscal Year 2022 is now available. This PTR is a user-requested, on-demand report which enables users to obtain the status of their data submission completeness related to the compliance threshold required for the SNF Quality Reporting Program (QRP).
Currently, Fiscal Year (FY) 2021 and FY2022 are available for user selection for this report to assist providers in reviewing Calendar Year (CY) 2019 and CY2020 data submission. The report has been revised for FY2022 to provide one overall compliance measure (Meets Threshold or Does Not Meet Threshold).
This report is available in the “SNF Quality Reporting Program” category in the CASPER Reporting application. Please refer to Section 13-SNF Quality Reporting Program in the CASPER Reporting MDS Provider User’s Guide for additional information about this report.
If you have any questions concerning this information, please contact the QTSO Help Desk at
help@qtso.com
or 1 (888) 477-7876.
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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 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 long in each year.
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CMS Region IV LTC Quality Improvement Initiative
Sleep Issues and Your Residents
Are your residents getting enough good quality sleep? Research has shown that older adults that have undiagnosed sleep apnea were also more likely to have additional ailments, such as high blood pressure, diabetes, heart disease, stroke and depression.*
Use the AMDA
Clinical Practice Guideline: Sleep Disorders
as a training tool for your staff. Access the FREE exam and have Nurses and Social Workers 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 and additional FREE CE exams for Nurses, Social Workers and Dietitians/Nutritionists on the website,
www.cpgltc.org.
For access to this password-protected website, contact the Help Desk at
help@cpgltc.org
.
Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients. Emerson M. Wickwire , Sarah E. Tom , Aparna Vadlamani , Montserrat Diaz-Abad , Liesl M. Cooper , Abree M. Johnson , Steven M. Scharf , and Jennifer S. Albrecht.
Journal of Clinical Sleep Medicine
. Published Online:15 Jan 2020;
https://doi.org/10.5664/jcsm.8128
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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Join Your Region's Nursing Home Collaborative
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Alliant Quality, the quality improvement group of Alliant Health Solutions (AHS), and our partners invite you to participate in the Southern Partners Action Collaborative for Excellence (SPACE), a nursing home collaborative. AHS is the Quality Improvement Network-Quality Improvement Organization (QIN-QIO) for Alabama, Florida, Georgia, Kentucky, Louisiana, North Carolina, and Tennessee.
This collaborative is designed to achieve excellence in nursing home care across our region. Together, we will achieve the following goals:
- Improve the mean total quality score for all nursing homes & increase percentage of NHs with a total quality score of >1258
- Reduce Adverse Drug Events (ADE) in nursing homes
- Reduce healthcare-related infections in nursing homes and hospitalizations for C.difficile infections
- Reduce ED visits and readmissions in short stay nursing home residents by 2024
Please see the attached
FLYER for additional information.
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Revised PBJ Data Specifications
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A revised version of the PBJ Data Specifications (Version 4.00.0) is 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.
On January 7, 2020, users will begin to receive a warning message on their PBJ Validation Reports stating that a file has been submitted with a fileSpecVersion that will be retired on June 1, 2020. Although this is a warning message and the files are currently accepted, please note that this edit will be changed to a fatal error on June 2, 2020. In preparation for this change, we encourage users to begin using the PBJ fileSpecVersion 4.00.0 as soon as possible.
The warning message that will appear on your PBJ Validation Report when using a PBJ Submission Spec versions 2.00.0 and 2.003 will be as follows:
-1018/WARNING
Message: The XML file was submitted using a fileSpecVersion value that will be retired on June 1, 2020. Refer to the CMS PBJ XML File Structure Standards described in the PBJ Data Submission Specifications Overview document. 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.
The new 4.00.0 fileSpecVersion and PBJ Data Specifications can be located in the
Downloads
section.
For those that use the Excel template to generate XML files, a new template can be found in the
Downloads
section.
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
help@qtso.com
.
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The MDS ASAP system was updated in December to include edit revisions contained in the MDS 3.0 Data Submission Specifications Errata, v3.00.3 issue IDs 04 and 05:
• Removal of edit -3941
• Addition of edit -3965
MDS 3.0 Report Changes
Additional updates have been made to several MDS 3.0 Provider Reports. The following sections of the CASPER Reporting User’s Guide were revised to include those updates:
MDS 3.0 Nursing Home (NH) Provider Reports (Section 20)
• MDS 3.0 Roster
• MDS 3.0 Activity
• MDS 3.0 NH Assessments with Error Number XXXX
MDS 3.0 Swing Bed (SB) Provider Reports (Section 21)
MDS 3.0 SB Assessments with Error Number XXXX
MDS 3.0 Nursing Home Assessment Maintenance Reports (Section 22)
• MDS 3.0 Facility Last Production Assessment
• MDS 3.0 Facility No Production Assessments
MDS Swing Bed (SB) Final Validation Report (Section 25)
MDS 3.0 SB Final Validation – User-requested CASPER report
MDS 3.0 SB Final Validation – Auto-generated Report
The MDS 3.0 SB Final Validation – Auto-generated report was also revised.
MDS Data Submission Specifications
Changes in the data submission specifications are in effect for assessments with a Target Date on or after October 1, 2019, unless otherwise noted in the data specifications.
Refer to the MDS 3.0 Item Change and MDS 3.0 Edit Change reports in the Data Submission Specification files for a list of the specific changes.
Note:
Edit changes for -3941 and -3965 contained in the MDS 3.0 Data Submission Specifications Errata, v3.00.3 are retroactive, applying to all assessments with target dates on or after October 1, 2019.
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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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