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
March 2022
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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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Important ePOC Notice
In January 2022, OIG announced that it will no longer accept Plans of Correction received through mail, in person delivery, fax or email.
Instructions and training information links regarding ePOC are available on the OIG website. Our staff will provide technical support to assist providers when needed to walk through the process.
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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Capacity to Consent
The State Operations Manual (SOM) reveals a resident has the right to consent to sexual activity; however, the facility must ensure the resident is assessed for the capacity to consent if the facility suspects the resident does not have the capacity to consent.
Recent inquiries had discovered some facilities utilize the BIMs score to determine if a resident has the capacity to consent. The BIMs score gives an idea of how well a person is functioning cognitively, at the time of the assessment. The score includes ranges from severely impaired cognition to cognition intact.
However, cognition and the capacity to consent are not the same. Additionally, competency does not necessarily insure capacity.
Cognition can be defined as the action or process of acquiring knowledge and understanding through thought, experience, and the senses. Competency can be defined as possession of a knowledge/skill or a legal authority or ability.
Capacity represents an assessment of the person’s psychological abilities to form rational decisions. Capacity is fluid – someone may have capacity regarding one situation and not with another situation.
Click HERE to continue reading...
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RAI 3.0 User’s Manual Update
The March update of Appendix B to the RAI 3.0 User’s Manual contains changes to the list of State RAI Coordinators, MDS Automation Coordinators, RAI Panel members, and CMS locations and contacts. To ensure accurate formatting, use a current version of Adobe Acrobat Reader to view this PDF. Web-based or mobile browser plug-ins may affect how the file is displayed. The file is located in the Downloads section.
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Updated Quick Reference Guide Available
An updated Quick Reference Guide is now available in the Downloads section of the SNF Quality Reporting Data Submission Deadlines webpage. The Quick Reference Guide provides high-level information on the SNF Quality Reporting Program, including frequently asked questions and helpful links.
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FREE to Kentucky Nursing Homes:
The Kentucky Wound Care Excellence Program
In July 2021, the Kentucky Office of Inspector General announced that Vohra Wound Physicians Management, LLC has been approved by the Centers for Medicare and Medicaid Services (CMS) to use Civil Money Penalty (CMP) funding to provide 150 scholarships for the Vohra Wound Care Course. The Program is designed specifically for registered nurses (RNs) and licensed practical nurses (LPNs) in certified nursing facilities to improve the care they deliver, raise their level of education, and close the existing knowledge gap in wound care provided across the State of Kentucky.
This opportunity will be offered on a first-come, first-serve basis until all the 150 scholarships are claimed. Nurses completing the course will receive 20 continuing education credits (CEUs). The course includes 11 downloadable learning modules, technical support/customer assistance, and program reporting. The program’s training structure ensures that scholarship recipients will have access to the materials indefinitely as an ever-present guide to sustain lessons learned.
For more information and to register for the program:
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Grant Opportunity for Purchase of Aids to Increase or
Improve Air Quality for In-person Visitations
As of February 2, 2022, certified nursing facilities may apply for up to an additional $3,000 of Civil Money Penalty (CMP) Nursing Home Visitation Aid Grant funds for the purchase of indoor portable fans and/or indoor portable air cleaners with high-efficiency particulate air (HEPA, H-13 or -14) filters, to increase or improve air quality to aid in-person visitation for residents. Expenses incurred on or after the release of Memorandum QSO-20-39-NH FAQ Revised, February 2, 2022, are eligible for reimbursement.
CMP Nursing Home Visitation Aid Grant funds are still available for the purchase of tents or other shelter for outdoor visitation and/or clear dividers, installation, installation materials and shipping costs for in-person visitation aids. All eligible expenses incurred on or after September 17, 2020, are eligible for reimbursements, up to a maximum of $3,000.
For more information and to apply for CMP Nursing Home Visitation Aid Grant funds:
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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.
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Jennifer Smith, RN
Contract RAI/Oasis/IDR-IIDR Coordinator
Office of Inspector General
Division of Health Care
275 E. Main St., 5E-A
Frankfort, KY 40621
Fax: (502) 564-6546
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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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All certified nursing facilities must sign up for ePOC. Please 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 yet 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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