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Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care

from all of us at the Office of Inspector General!

SNF QRP Listening Session: Possible Expansion of SNF Data Collection and Submission to All Residents Regardless of Payer

The Centers for Medicare & Medicaid Services (CMS) has published a summary report on the virtual Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Listening Session that was held on October 1, 2024, by RTI International. This session was held to seek feedback from clinical staff, MDS coordinators, administration and management staff, and software vendors on the possible expansion of collection and submission of Minimum Data Set (MDS) assessment data used for the SNF QRP to include all residents receiving short-term skilled care in a SNF regardless of their payer. The report presents a summary of the presentation for each discussion topic, input from interested parties for each of the discussion questions, and key findings. The summary report also includes the feedback received via email in the 30 days following the event. The report can be found in the Downloads section on the SNF QRP Measures and Technical Information webpage.

Learn More & Register at https://form.jotform.com/243465405832154

MDS 3.0 Quality Measures User's Manual v 17.0 and

Accompanying Risk Adjustment Appendix File

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User's Manual v17.0 and accompanying Risk Adjustment Appendix File are now available. The MDS 3.0 QM User’s Manual V17.0 will be effective beginning January 01, 2025 and contains detailed specifications for the MDS 3.0 QMs. A Notable Changes section in the document summarizes the major changes from MDS 3.0 QM User’s Manual V16.0. The Risk Adjustment Appendix File is a reference to be used in conjunction with the MDS 3.0 Quality Measures User’s Manual v17.0 and contains coefficient values used to calculate the risk-adjusted quality measures. There are no coefficient changes to the Risk Adjustment Appendix from v16.0 to v17.0 since specification updates did not significantly change the coefficient values.

The manual and risk adjustment file can be found in the Downloads section on the NHQI Quality Measures webpage.

Online MDS Training

Minimum Data Set training, hosted annually by the Kentucky Office of Inspector General and presented by Myers and Stauffer LC, is available on TRAIN:

• OIG DHC MDS Webinar 1 Nursing Restorative Documentation October 2024 1124033
• OIG DHC MDS Webinar 2 Supportive Documentation Requirements Part 1 October 2024 1124035
• OIG DHC MDS Webinar 3 Supportive Documentation Requirements Part 2 and MDS Item Set Updates October 2024 1124037
• OIG DHC MDS Webinar 4 Section A Completion October 2024 1124039
• OIG DHC MDS Webinar 5 Section M Completion October 2024 1124040
• OIG DHC MDS Webinar 6 Chapter 6 PDPM October 2024 1124042

Note that last year's "Back to Basics" series is also still available!

• OIG DHC MDS RAI Manual Chapter 1 October 2023 1113709
• OIG DHC MDS RAI Manual Chapter 2 October 2023 1113710
• OIG DHC MDS RAI Manual Chapter 3 October 2023 1113711
• OIG DHC MDS RAI Manual Chapter 4 October 2023 1113712
• OIG DHC MDS RAI Manual Chapter 5 October 2023 1113713
• OIG DHC MDS RAI Manual Chapter 6 October 2023 1113714

The Kentucky Board of Nursing has approved contact hours for Kentucky RNs and LPNs upon completion, assessment, and evaluation of most individual sessions. Kentucky LTC Administrators will also receive contact hours.

If you have any questions, you may contact Darlene.Cox@ky.gov.

Free Training for Nursing Facility Staff

The Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) was established by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS). It provides mental health and substance use training, customized technical assistance and resources to certified Medicare and Medicaid nursing facility staff who care for residents with a variety of behavioral health conditions at absolutely no cost.

Check out resources today!

www.nursinghomebehavioralhealth.org

Division of Health Care Contact Information

Central Office

Carrie Storms, Director

Marissia Izlar, Assistant Director

Andrea Willhite, Assistant Director

275 E. Main St., 5E-A Frankfort, KY 40621

Phone: 502-564-7963

Fax: 502-564-6546

Western Enforcement Branch

Terri Gipson, Regional Program Manager

Samuel Ellsworth, Human Services Program Branch Manager

901 B South Main Street, Hopkinsville, KY 42240

Phone: 270-889-6052

Fax: 270-889-6089

Northern Enforcement Branch

Chuck Ballou, Regional Program Manager

Carmen Ferguson, Human Services Program Branch Manager

L & N Building 10-W, 908 W. Broadway, Louisville, KY 40203

Phone: 502-595-4958

Fax: 502-595-4540

Southern Enforcement Branch

Phyllis Monhollen, Regional Program Manager

Casey Shelley, Human Services Program Branch Manager

116 Commerce Ave., London, KY 40744

Phone: 606-330-2030

Fax: 606-330-2054

Eastern Enforcement Branch

Gae Vanlandingham, Regional Program Manager

Will Hendrickson, Human Services Program Branch Manager

455 Park Place, Suite 120A, Lexington, KY 40511

Phone: 859-246-2301

Fax: 859-246-2307

Kentucky's Top 10 Citations

for Nursing Homes

Health Care

Life Safety Code

Emergency Preparedness

Informal Appeal of Survey Findings

Every Long Term Care provider has the right to both an informal and formal appeal process following receipt of a completed Form CMS-2567. There are two informal appeal processes: Informal Dispute Resolution (IDR) and Independent IDR (IIDR).

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.

Please complete the Confidentiality Agreement and submit via email, fax, or mail to:

All certified nursing facilities are required to 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.

Click here for the CMS security rules.

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 contact Zakary Carter, ASPEN Coordinator, at Zakary.Carter@ky.gov.

Have you notified your residents?

Click the link below to download and/or print the contact list for various agencies.

REQUIRED Agency Contact Information for Residents of LTC Facilities

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.

Regional Map

Contact Information

CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.

Policy and Memos 

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:

ITD.APP@ky.gov  

LTC Facility Self-Reported

Incidents & Complaints

Email addresses were 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. 

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.



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.

Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care 

DHC Leadership Team:

Tricia Steward

Acting Inspector General

Carrie Storms

Director

Marissia Izlar

Assistant Director

Andrea Willhite

Assistant Director