!! PLEASE SEE EPOC ANNOUNCEMENT FOR URGENT DEADLINE !!
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You're receiving this email because of your relationship with the Office of Inspector General, Division of Health Care. Thank you for your continued commitment to serving the citizens of our Commonwealth!
Cabinet for Health and Family Services
Office of Inspector General
Division of Health Care
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Long Term Care Provider Newsletter
July 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 websites for the most up-to-date news and information:
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"It's a Wrap"
After a career of forty-one years in health care, which includes twenty-seven years in public service, seven years with the Federal government and the last 20 years with the Commonwealth, I have decided to end this chapter of my life by retiring and start a new one. I have made many acquaintances over the past 20 years, starting as a surveyor with the Office of Inspector General in 2001 and ending as the Director of the Division of Health Care. I have enjoyed working with you, learning with you, and sharing the same goal of ensuring the best health care for our Medicare and Medicaid beneficiaries. I thank you for your valued support over the years.
Wishing you all the best,
Jackie Aitkin
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Division of Healthcare Welcomes New Director
A little bit about myself, I have 11 years of state service and I began my career as a surveyor with the Office of Inspector General in 2005. In 2018, I was hired as a Human Services Supervisor and was promoted in 2019 to the Regional Program Manager position. In May of 2020, I was selected for the Assistant Director position in Central Office. I have 29 years of nursing experience in the areas of Quality/Risk Management, Forensic Psychiatry, Surgical Services, Regulatory and Licensure, and thirteen years were in management positions. In addition, I am CMS certified in Acute Hospital, Psychiatric Hospital, Home Health, EMTALA and Long Term Care. I also earned a Bachelor’s Degree in Criminal Justice. I am looking forward to this new role and working with everyone.
Belinda Beard, BS, RN
Division Director effective August 1, 2021
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Electronic Plan of Correction for Certified Nursing Homes
The Electronic Plan of Correction (ePOC) application was initiated in Kentucky on June 1, 2016. The ePOC application eliminates the need for paper-based communication between Certified Nursing Home providers and the Office of Inspector General, Division of Health Care, when submitting and reviewing plans of correction. Once providers complete the ePOC enrollment process, they can begin accessing the CMS-2567 Statement of Deficiencies (SOD) and enter their Plan of Correction (POC) via the secure website created by CMS.
Kentucky currently has 162 certified nursing facilities utilizing ePOC. Participation was voluntary; however, our CMS Atlanta location has requested we no longer offer two options for submitting the POC. Therefore, it will be mandatory for the remaining Certified Nursing Homes to enroll in ePOC by January 1, 2022.
Instructions and training information links are available on the OIG website. Our staff will provide technical support to assist providers when needed to walk through process. The contact information is located in the ePOC Accounts section of this newsletter.
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Root Cause Analysis - Part II of III
Last month you were introduced to Root Cause Analysis (RCA) and the seven steps used to investigate events. This month, we will take a deeper dive into the seven steps and how to implement them.
Step 1 – Identify the event to be investigated and gather preliminary information
Events can come from many sources and you can identify them in many ways. The facility should develop a process for choosing events that will be investigated using the RCA process. When determining events to investigate, high priority should be given to events that resulted in significant resident harm or death and other events the facility is required by regulation to investigate. Also consider doing an RCA for “near miss” or “close call” events that could have resulted in harm to the resident, but did not, either by chance or timely intervention.
Step 2 – Select team members and a team facilitator
Leadership should designate a facilitator and then work together with the facilitator to develop a team. Team members should have knowledge of the processes and systems involved in the event that will be investigated.
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Leading the Way in Autonomous Infection Prevention & Control
On March 11th, Governor Andy Beshear announced that CMS had approved a CMP grant to provide the care.ai Smart Entry Platform, along with Smart Badges for employees, at 285 Medicare-certified nursing homes in Kentucky at no cost for 2 years’ use. This contact-free temperature screening and vaccination tracking solution will help reduce the spread of COVID-19, the flu, and other infectious diseases. This program also covers a team to deploy the solution in your facility and provides training videos to help manage the devices.
This Long-Term Care Autonomous Screening and Vaccine Tracking Project was proposed by senior living provider Trilogy Health Services’ nonprofit, the Trilogy Foundation, and is funded through the CMS Civil Money Penalty Reinvestment Program, with the technology and services provided through partnership with care.ai. The CHFS Office of the Inspector General fully supports this program as a strong advancement in the protection of Kentucky’s most vulnerable residents, many of whom have underlying chronic conditions, compromised immune systems, and advanced age.
To learn more about how to take advantage of this program, please contact Patrick McIntyre from care.ai at patrick.mcintyre@care.ai or (321) 698-5733.
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SNF Quality Reporting Program: Non-Compliance Notifications
CMS is providing notifications to Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) Swing Beds (SBs) that were determined to be out of compliance with SNF Quality Reporting Program (QRP) requirements for calendar year (CY) 2020, which will affect their fiscal year (FY) 2022 Annual Payment Update (APU). Non-compliance notifications will be distributed by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ CASPER folders in QIES on July 14, 2021. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 13, 2021. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification letter and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.
Please note: Any reconsideration containing protected health information (PHI) will not be processed. All PHI must be removed in order for a reconsideration to be reviewed.
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Upcoming QIES/iQIES Service Center Hold Times
Due to the upcoming PBJ submission period, the QIES/iQIES Service Center is expecting an increase in call volume and emails between August 1st and August 14th, 2021, which may result in longer hold times.
To minimize wait times and ensure successful PBJ submission, CMS recommends the following:
*Use One Method to Report Issues:
Due to the increase in volume at the QIES/iQIES Service Center, and to minimize backlog of contacts, please use only one method of reporting for the same issue (email or phone). Note: Cases are processed in the order they are received, regardless of the manner in which the Service Center was contacted. Please allow time for processing.
*Submit Your Data Early:
We encourage you to submit your PBJ data early during the submission period. Early submission will allow you plenty of time for Service Center assistance if needed.
*Call the Service Center at Off-Peak Hours:
We strongly recommend calling the Service Center during off-peak hours (8:00 AM-10:00 AM ET OR 2:00 PM-8:00 PM ET).
For More Information
Contact the QIES/iQIES Service Center at 1-800-339-9313, Monday through Friday, 8:00 AM - 8:00 PM ET or by e-mail. Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.
Reminder: To receive assistance more quickly, consider calling during non-peak hours—before 10:00 AM and after 2:00 PM ET.
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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
Vacant
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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