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Cabinet for Health and Family Services
Office of Inspector General
Division of Health Care
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Long Term Care Provider Newsletter
November 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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Facility Information Updates
Please remember to keep the Office of Inspector General up-to-date with any change in administrator and/or their contact information. For communication and recordkeeping purposes, it is vital that we have current facility information. To make updates, please submit the following on company letterhead to the address listed:
- Full Name of New Administrator
- License Number of New Administrator (if applicable)
- Email Address of New Administrator
- Effective Date of the Change
Office of Inspector General
Division of Health Care
ATTN: Operations Branch
275 E. Main St., 5E-A
Frankfort, KY 40621
Please direct any questions to our office at (502) 564-7963.
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ePOC Deadline 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.
Our CMS Atlanta location has requested we no longer offer two options for submitting the POC. Therefore, it will be mandatory for all 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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Holiday Decorations
by Shelley Singleton
The last two years have brought about so many challenges for all of us. COVID-19 has introduced us to a world none of us would have ever thought we would see. As the year winds down and the Christmas season is upon us, the desire to shed some happiness and bring some light into the lives who have been affected is ever present and seems to be taking shape a little earlier than year’s past. With the desire comes the decorations — to deck the halls with trees, wreaths, garlands, lights, tinsel and other traditional accessories to evoke a spirit of celebration and warmth, that we hope carries into the New Year.
Mindful of the risks, many healthcare facilities develop guidelines for holiday decorations—both in public spaces and residents’ private rooms. Some facilities choose to be more restrictive than others. What follows is a summary of best practices based on regulations and recommendations from a variety of sources, including the National Fire Protection Association, the Consumer Products Safety Commission, and healthcare facilities throughout the country.
Safe Trees, Garlands and Wreaths
- Artificial trees and decorative foliage are generally safer — less likely to catch fire, that is — than natural, cut trees and branches. If you opt for one or more artificial trees and foliage, make sure they are labeled Fire Resistant. (It is best to make sure that claims of fire resistance are documented by Underwriters’ Laboratories (UL) or a similar third-party authority. Some materials sourced from outside the U.S. have been known to carry false labeling.)
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If you have put up a natural tree, check weekly to make sure the needles are still vibrant green. Keep natural trees hydrated by placing them in a stand that has a receptacle for water at the base. Keep it filled, and don’t leave a natural tree in place indoors for more than four weeks. That means for many facilities, the tree needs to come down by Jan. 6.
- Keep trees away from heat sources such as fire places and heaters.
Safe Lighting and Electrical Cords
- Use only lighting strands that carry the UL label.
- Inspect wires, plugs and sockets for corrosion and other damage before hooking them up and displaying them. Repair or replace any deficient parts. Test lights by plugging them in and letting them stay on for 15 minutes to ensure that they’re safe and sound.
- Check the amperage rating of the circuit that will serve a lighting array, and add up the total draw of the combined lighting strings. Generally speaking, it’s best not to join more than three light strings (200 miniature bulbs or 50 large bulbs) and plug them into a single receptacle.
- Do not string holiday lights on metallic trees.
- Use heavy-duty, three-wire extension cords with three-prong plugs to power holiday lights. Plug them into power strips with built-in ground-fault circuit interrupters (GFCIs). Never extend a circuit by plugging one power strip into another.
- For outdoor lighting displays, make sure that the lights, extension cords and GFCI-equipped power strips are rated for outdoor use.
- Arrange extension cords used to power holiday lights so that they don’t present a trip hazard.
More Holiday Decorating Issues
- The NFPA Life Safety Code® limits the amount of combustible materials that can be displayed on interior walls and ceiling finishes to 10% of the aggregate wall and ceiling areas of any room or space covered in combustible materials. This includes paintings and photographs. Any decorations beyond the initial 10 percent must be documented as flame retardant, and the documentation must be maintained by the department responsible for mounting the display.
- Many facilities prohibit hanging decorations from ceilings. In any case, decorations should not be placed closer than 18 inches from sprinkler heads.
- Decorations should not interfere with the visibility of exit signs.
- Some facilities prohibit trees other decorative displays that occupy floor space in entryways and hallways, in deference to NFPA rules against blocking means of egress.
While the code regulations and most of the suggestions above must be observed in the common areas of healthcare facilities, it’s also a good idea to keep an eye on how residents decorate their private rooms and suites. Unsafe lights and extension cords present risks for fire, tripping and electrocution.
None of this is meant to dampen the holiday spirit, but rather to suggest practices to ensure that colleagues and residents alike — everyone in your care — enjoys a happy, healthy and safe holiday season.
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Kentucky LTC2Prepare Ends
As of October 31, 2021, the CMP grant for Kentucky LTC2Prepare ended. Over the course of 4 years, 9 conferences were held across the Commonwealth training all levels of LTC staff (1900+) on the Final Rule on Emergency Preparedness among other emergency preparedness topics.
The website, www.ltc2prepare.org, will remain active and will be accessible to all KY LTC. Resources on the website include:
- KY LTC Emergency Preparedness Manual
- KY Electronic Hazard Visibility Analysis (HVA) Tool
- KY LTC Family Council Manual
- Earthquake Preparedness Guide for LTC Facilities
- Videos on Earthquake Preparedness
FREE CE for Nursing and Certificates of Completion for other staff can be earned by watching video modules and passing short exams. Sixteen (16) video modules with exams are available.
EP301: Catastrophic Planning
- Resilience and Stress Management
- Changing Hazards and the LTC Hazard Vulnerability Analysis (HVA) Communication Planning/Kentucky LTCO Family Council Initiative
- COVID-19 and Infection Control
- It's Not If But When...Minimizing Risks for Earthquakes
- Earthquakes: Minimizing Impact to Your Facility/Hazard Hunt
- Protecting Your Staff, Residents and Self/Earthquake Resources
- Catastrophic Evacuation and Transportation
- Catastrophic Medical Surge Planning/Catastrophic Wrap-Up
EP101: Basic Emergency Preparedness
- Understanding Your Risk and Vulnerability
- Developing an Effective Emergency Preparedness Program
- Continuity of Operations Planning (COOP)
- Developing your Hazard Vulnerability Analysis
- Shelter-In-Place (S-I-P)
- Testing and Training
- How to Conduct a Tabletop Exercise
Each KY LTC has a unique user id and password. For assistance with obtaining the facility user id and password, contact the Help Desk at help@ltc2prepare.org.
LTC2Prepare Initiative was funded through CMS Grant #2017-04-KY-0808 and the Kentucky Office of the Inspector General, Grant # PON2 723 1800000928 1.
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MDS Training Available
Minimum Data Set training, hosted annually by the Kentucky Office of Inspector General and presented by Myers and Stauffer LC, is now available on TRAIN. This free course has been split into six webinars that review the RAI Manual with an emphasis on PDPM items:
The Kentucky Board of Nursing has approved contact hours for RNs, LPNs, and LTC Administrators upon completion, assessment, and evaluation of each session. (Please note that you must have an individual TRAIN account in order to receive credit.)
Disclaimer: The Kentucky Board of Nursing approval of an individual continuing education provider does not constitute endorsement of program content.
Please contact Melissa Richard with any questions by email or at 502-564-7963 x.3310.
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MDS ASAP Update
A minor update to the MDS ASAP system will occur on November 20, 2021. Items included in this release are as follows:
Integrating the Java based version of the PDPM JAR v2.0001. This update to the MDS ASAP system will be effective as of 11/20/2021. The new version of the PDPM incorporates fixes for two bugs introduced on 10/1/2021.
a. A correction to a logic issue on “Behavioral Symptoms and Cognitive Performance” under Nursing payment component. When C0100 and C0500 are both dashes (not assessed), the grouper returned an incorrect nursing classification. A nursing component of BAB1 may be returned in error.
b. A correction to the NTA comorbidity score calculation when calculating I8000: End-Stage Liver Disease and I8000: Immune Disorders. These comorbidities should only count as 1 point each. V2.0000 was counting these comorbidities as 2 points each.
This grouper code works for all assessments with a target date of 10/1/2019 or greater.
Please go to the MDS 3.0 Technical Information page listed below to download and implement version 2.0001 of the PDPM. Failure to update the PDPM version to 2.0001 as of 11/20/2021 will result in a warning code error -3935b: Incorrect RUG/PDPM Version: The submitted version of the RUG/PDPM does not match the value calculated by the QIES ASAP System.
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SNF Provider Preview Reports - Now Available
The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores on quality measures, which will be published on Care Compare (CCXP) and Provider Data Catalog (PDC) during the January 2022 refresh.
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New Resources Available
Job Aids – GG0130A. Eating, GG0130B. Oral Hygiene, GG0130C. Toileting Hygiene, GG0130E. Shower/Bathe Self, GG0130F. Upper Body Dressing, GG0130G. Lower Body Dressing, and GG0130H. Putting On/Taking Off Footwear
Quick Assessment Reference Pocket Guides / Badge Buddies for Coding
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PAC Quality Reporting Programs:
Updated 3-Course Training Series for Section GG
The Centers for Medicare & Medicaid Services (CMS) is offering an updated web-based training series on the assessment and coding of Section GG. This training is intended for providers in the following post-acute care (PAC) settings: Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs). It is designed to be used on demand anywhere you can access a browser. This training series consists of three courses:
Each course includes interactive exercises to test your knowledge related to the assessment and coding of Section GG items.
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SNF CCXP Refresh with Revised DTC Measure Data
The Skilled Nursing Facility (SNF) refresh with revised Discharge to Community (DTC) measure data is now available. Please visit the Skilled Nursing Facility web page within Care Compare (CCXP) and Provider Data Catalog (PDC) to view the updated quality data.
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FREE to Kentucky Nursing Homes:
The Virtual Dementia Tour® Dementia Training Program
In January 2020, the Kentucky Office of Inspector General announced that Second Wind Dreams® (SWD®) has been approved by the Centers for Medicare and Medicaid Services (CMS) to use Civil Money Penalty (CMP) funding in 125 Kentucky skilled nursing homes. The project assists nursing home staff to improve care for dementia residents by providing hands-on, experiential training using the patented Virtual Dementia Tour® (VDT®). The VDT has been scientifically proven to build a greater understanding of dementia using sensory tools and instructions.
A Second Wind Dreams Certified VDT Trainer will train designated nursing home contacts to conduct the VDT for their staff, as well as evaluate care staff and document improvements in caregiving. Once the training is complete, the nursing home may conduct the VDT as often as they like for their staff. Some choose to offer it as part of their new employee orientation. With some additional training, they can also invite family members and the public to their community to experience the VDT.
For more information and to apply:
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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
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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