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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
March 2020
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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 website for the most up-to-date news and information:
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Prioritization of Survey Activities
The Centers for Medicare & Medicaid Services (CMS) is committed
to taking critical steps to ensure America’s health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (COVID-19). On Friday, March 13, 2020, the President declared a national emergency, which triggers the Secretary’s ability to authorize waivers or modifications of certain requirements pursuant to section 1135 of the Social Security Act (the Act). Under section 1135(b)(5) of the Act, CMS is prioritizing surveys by authorizing modification of timetables and deadlines for the performance of certain required activities, delaying revisit surveys, and generally exercising enforcement discretion for three weeks.
During this three-week timeframe,
only
the following types of surveys will be prioritized and conducted:
- Complaint/facility-reported Incident Surveys: State survey agencies (SSAs) will conduct surveys related to complaints and facility-reported incidents (FRIs) that are triaged at the Immediate Jeopardy (IJ) level. A streamlined Infection Control review tool will also be utilized during these surveys, regardless of the Immediate Jeopardy allegation.
- Targeted Infection Control Surveys: Federal CMS and State surveyors will conduct targeted Infection Control surveys of providers identified through collaboration with the Centers for Disease Control and Prevention (CDC) and the HHS Assistant Secretary for Preparedness and Response (ASPR). They will use a streamlined review checklist to minimize the impact on provider activities, while ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.
In addition, the following enforcement actions will be suspended, until revisits are again authorized:
- Imposition of Denial of Payment for New Admissions (DPNA), including situations where facilities that are not in substantial compliance at 3 months, will be lifted to allow for new admissions.
- Per day civil money penalty accumulation and imposition of termination for facilities that are not in substantial compliance at 6 months will be suspended.
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“I would like to request an IDR.
What do I need to know?”
The purpose of the IDR is to give the facility an opportunity to contest the factual accuracy of a cited deficiency after any survey.
If a facility wishes to request an IDR they must:
- Submit the request in writing on or before the 10th calendar day following the receipt of the Statement of deficiencies (SOD). (The day the facility receives the SOD is considered day 0.)
- The request must be submitted to the IDR Coordinator, Chrystal Daugherty either by mail at 116 Commerce Ave., London, KY 40744 or via email at chrystalr.daugherty@ky.gov.
What are the types of IDR’s that a facility may request?
- Desk review - Available for ANY cited deficiency
- Telephone Review – Available for ANY cited deficiency
- Face to Face Review – Available for a cited deficiency that is cited at a scope/severity of a G, H, I, J, K, or L or a cited deficiency that is substandard quality of care
The request must include:
- An explanation of the deficiencies that are being disputed
- Supporting information to explain the facility’s reason that the deficiency should not have been cited
- The desired outcome for each disputed deficiency.
Please remember that no new information may be introduced.
When the facility requests an IDR they can expect to receive an acknowledgement letter that their request was received. If the request does not meet the criteria for the IDR, the facility will be notified.
The facility can expect a response from the IDR Coordinator regarding the outcome of the IDR
within 35 working days.
Special note: Requesting an IDR does not limit the legal appeal processes that are afforded to Long Term Care Facilities under federal laws and regulations. Requesting an IDR does not relieve the facility of the requirement to provide a plan of correction or to implement corrective action and does not delay the effective date of an enforcement action that may result from the survey findings
.
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Submission of Incidents and Complaints
When submitting LTC Facility Self-Reported Incidents, or reporting a possible violation of regulatory requirements, please submit them only once, either through fax or email, to the Complaint Coordinator at the appropriate OIG Branch.
Please remember to include staff and resident names in your reports for faster processing.
Email addresses and fax numbers for each Branch can be found
HERE.
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LTC2Prepare EP 301 Conferences Postponed
The LTC2Prepare EP 301 conferences scheduled for March 24-25 (Louisville) and April 29-30 (Berea College) have been postponed until late summer/early fall. Registration information will be sent once the new dates have been scheduled.
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CMS Region IV LTC Quality Improvement Initiative
On-line FREE CE Training at Your Fingertips
Isolated at home? Continue to update your skills and earn FREE CE Credits for Nursing, Social Work and Dietitians/Nutritionists or Certificates of Completion for other LTC staff.
Nurses can earn up to 42 CE credits - Social Workers can earn up to 29 CE credits - Dietitians/Nutritionists can earn up to 20.5 CE credits – 20 Certificates of Completion for all LTC staff.
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New Local Contact for Alliant Quality, Kentucky’s QIN-QIO
Alliant Health Solutions, the Medicare QIN – QIO for Kentucky, wants you to get to know Beth Greene, Senior Quality Advisor and local contact for Alliant Quality, the quality improvement group for Alliant.. Beth started with Alliant on February 24
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, and looks forward to working with nursing home partners and stakeholders across the state of Kentucky. Prior to coming on board with Alliant Quality, Beth was with Alabama Quality Assurance Foundation (AQAF), the QIO for Alabama. She is a graduate of the University of Alabama at Birmingham and the University of Tuscaloosa. Beth received her master’s degree from the University of Tuscaloosa in Social Work with a concentration in geriatrics and healthcare administration. Beth is a licensed social worker with the Alabama State Board of Social Work Examiners. She has worked in the healthcare industry for 25+ years and her experience includes social work practice and quality/performance improvement in both the acute care and long term care setting. Most of her experience has been in the Long Term Care Setting in the areas of quality improvement, regulatory compliance, strategic planning, business development and social services. Beth has worked with both the corporate sector and smaller independent consulting firms. She particularly enjoys working with nursing home teams on the reduction/elimination of antipsychotic medications and behavior management. A fun fact about Beth is that her son moved to Louisville, KY, last summer to train with the Louisville Ballet!
Alliant Quality is currently in its recruitment phase for the CMS 12
th
Scope of Work (SOW) and invites you and your team to participate in the Southern Partners Action Collaborative for Excellence (SPACE), a nursing facility collaborative, to achieve your quality improvement goals. Participation is easy, and the benefits are many! And since we are your Medicare Quality Improvement Organization, everything we do is
free
! The benefits of participating include:
- Free training/coaching on QAPI, data, and quality projects
- Free technical assistance and resources
- Free webinar and collaborative learning events
- And so much more
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CMS Delaying Implementation of 10/1/20 MDS 3.0 v1.18.1 Release
CMS is delaying the Minimum Data Set (MDS) 3.0 v1.18.1 release, which had been scheduled for October 1, 2020, in response to stakeholder concerns. The MDS item sets are used by Nursing Home and Swing Bed providers to collect and submit patient data to CMS. This MDS data informs payment, quality, and the survey process.
In December of 2019, CMS posted a draft of the MDS 3.0 item set v1.18.0 and received feedback from our stakeholders. We would like to thank the stakeholders for sharing their concerns regarding the proposed changes to the MDS 3.0 item sets and more specifically the removal of the Section G items from OBRA assessments.
The MDS changes CMS planned for October 1, 2020 will now be delayed. CMS staff are actively engaged in discussions with various stakeholders, regarding the various changes, the impacts of these changes, as well as, the compressed timeline to educate and train facility staff and update software and IT systems.
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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
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. A
ll 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 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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