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 & Family Services
Office of Inspector General
Division of Health Care
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Long Term Care Provider Newsletter
March 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 website for the most up-to-date news and information:
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A Message from the Inspector General
Providers and Staff:
This month represents a year since COVID-19 was first identified in the state of Kentucky. We very quickly pivoted to protect the lives of those we serve. It was a group effort with significant collaboration and coordination from both state agencies, local leaders, and providers. I want to appreciate and acknowledge that this past year has not been easy, but you have continued to stay engaged and remained vigilant in protecting residents. The federal Long-term Care Vaccination Program is complete and now we look towards a vaccine maintenance program for those who still need to be vaccinated. We are now at a point where we can see the light at the end of the tunnel. We will get through this soon and my hope is that we learn from it. There is no time like now to look at what worked well and what needs to be addressed. I look forward to seeing what we, as Team Kentucky will be able to accomplish going forward.
Thank you
Adam Mather
Inspector General
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CMS Targeted COVID-19 Training for Frontline Staff and Management
In November 2020, CMS announced an Urgent Call to Action regarding the CMS Targeted COVID-19 Scenario-Based Training for Frontline Nursing Home Staff and Management - urging nursing homes to take advantage of this training. CMS is tracking completion of this training and recently started pulling a Quality Safety and Education Portal (QSEP) training report around the 15th of each month. Based on the March 2021 tracking report from CMS, Kentucky has 57 nursing homes reflecting 0% training completion.
If your nursing home has not completed this training we encourage you to consider establishing a schedule for completing this training. If you are uncertain about percentage completion or would like additional information about this training offering, please reach out to the QIN-QIO, either Brandi Claggett brandi.claggett@alliantquality.org or Beth Greene beth.greene@alliantquality.org for guidance.
Additionally, CMS shared the following work-around if you are interested in group training:
Nursing homes interested in offering small group trainings will need a record of registration, completed pre/posttests (including scores) and evaluations. The easiest way would be to have individuals register (they can use a cell phone, tablet or computer), take the pre-test, watch the class as a group and then log into QSEP to complete the post test and evaluation.
Instructions on how to access the training is available on the Quality, Safety & Education Portal (QSEP) at:
Again, please feel free to reach out with any questions.
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Infection Prevention "Surveillance, Tracking and
Reporting" (STAR) Facilities Shop Talk -
Visitation Updates and COVID-19 Vaccine Data Entry to NHSN
April 15, 2021 at 2-3:00 p.m. ET/ 1-2:00 p.m. CT
Join the Alliant Quality team for an overview of the Visitation Updates and COVID-19 vaccine data entry to NHSN. As always, we will also conduct a live question and answer session to help with your immediate needs in accessing, using, and improving NHSN reporting.
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Still have questions about accessing NHSN or the SAMS Grid Card?
Take a minute to watch Shop Talk Shorts!
We’ve created 2-3 minute videos with answers to FAQs about getting access to NHSN. Please take a few minutes to watch the videos before the next Shop Talk so we can dive into NHSN and data quality topics on our calls together! New videos will be added periodically -- topics include:
*NEW* How do you find out who has access and rights for your facility account?
*NEW* I used my grid card at my previous facility. Can I use it to access my new facility?
*NEW* My administrator added me as a user to our facility's NHSN account, but I can't login.
How to change your email address in NHSN
How to upgrade to level-3 access in NHSN
I am new and no one at my facility has access to NHSN. How do I get access?
How do I add users and rights to our NHSN account?
I am leaving the facility. How do I reassign the facility administrator?
How do I put staff data in the new POCT module?
How do I find my facility NHSN data on the CMS website and check to see if it passed quality assurance?
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Covid-19 Tips for Dementia Caregivers
Most likely, dementia does not increase risk for COVID-19, the respiratory illness caused by the new coronavirus, just like dementia does not increase risk for flu. However, dementia-related behaviors, increased age and common health conditions that often accompany dementia may increase risk.
For example, people with Alzheimer's disease and all other dementia may forget to wash their hands or take other recommended precautions to prevent illness. In addition, diseases like COVID-19 and the flu may worsen cognitive impairment due to dementia.
As communities and care services begin reopening, it is important for caregivers to consider the risks and take additional safety precautions for people living with dementia.
You may also visit the Care and Support page to see our education programs and support groups.
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The Office of Inspector General is grateful to the Alzheimer's Association for permission to share these resources with our surveyors and providers. |
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Q&A from your State RAI Coordinator
My resident has received the monoclonal antibody Bamlanivimab for the treatment of Covid-19. What is a monoclonal antibody and how do I code this on the MDS... transfusion or IV medication?
Our bodies produce antibodies naturally to help the immune system recognize germs that cause disease, such as the COVID-19 virus. Monoclonal antibodies are immune system proteins that are created in a laboratory and are made by cloning a unique white blood cell. Bamlanivimab is a monoclonal antibody developed to treat the COVID-19 virus.
Monoclonal antibody treatment would be coded as IV medication in Section O of the MDS.
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FREE Online MDS Training Still Available
Minimum Data Set training, hosted annually by the Kentucky Office of Inspector General and presented by Myers and Stauffer LC, is still available on TRAIN. This free course has been split into six webinars that review the new MDS and Resident Assessment Instrument manual updates and revisions from the Centers for Medicare and Medicaid Services (CMS), effective October 1, 2020:
- OIG DHC MDS Updates Effective October 1 2020 Session 1 (Search for course 1093110)
- OIG DHC MDS Updates Effective October 1 2020 Session 2 (Search for course 1093111)
- OIG DHC MDS Updates Effective October 1 2020 Session 3 (Search for course 1093112)
- OIG DHC MDS Updates Effective October 1 2020 Session 4 (Search for course 1093113)
- OIG DHC MDS Updates Effective October 1 2020 Session 5 (Search for course 1093114)
- OIG DHC MDS Updates Effective October 1 2020 Session 6 (Search for course 1093115)
The Kentucky Board of Nursing has approved contact hours for sessions 2, 4, 5, and 6. Kentucky RNs, LPNs, and LTC Administrators will receive CEs upon completion, assessment, and evaluation of each session. (Please note that you must have an individual TRAIN account in order to receive credit.)
Disclaimer Statement: 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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LTC2Prepare Training to be Resumed
EP 301 In-Person Conference on Catastrophic Planning
Scheduled for June 22-24, 2021
The EP301 – Catastrophic Planning conference is scheduled for June 22 and 23. The conference will be held at the Parklands at Floyds Fork in Louisville. The conference will be held in the Gheens Foundation Lodge. Registration for this FREE conference will be available soon. Topics will include: psychological first aid during a disaster; communication planning; using the electronic HVA tool; It's Not if but when…The New Madrid Fault and earthquake mitigation planning and minimizing damage; Catastrophic evacuation and medical surge planning, infection control and Lessons Learned from COVID-19.
Courses will offer Continuing Education hours from NAB/NCERS for Nursing Home Administrators and from the Kentucky Board of Nursing for Continuing Education through University of Louisville Hospital, provider number 4-0068-7-20-1141. CEs will be available for all alternate learning opportunities whether in-person or on-line conferences. More information coming soon!
Need information on COVID-19? Access the website www.ltc2prepare.org for up-to-date information on COVID-19 from the Kentucky Office of Inspector General, Centers for Medicare and Medicaid and the Centers for Disease Control and Prevention. The Kentucky LTC Emergency Preparedness Manual and other emergency preparedness resources are available on the website as well.
For assistance for your facility username and password, contact the Help Desk at help@ltc2prepare.org.
LTC2Prepare Initiative is 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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NEW TRAININGS AVAILABLE
Section J: Health Conditions: Coding the Standardized Patient Assessment Data Elements (SPADEs) Related to Falls
The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training that provides an overview of the assessment and coding of the standardized patient assessment data elements (SPADEs) related to falls in Section J: Health Conditions. This 45-minute course is intended for providers in Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs), and is designed to be used on demand anywhere you can access a browser. The course is divided into six sections and includes interactive exercises to test your knowledge related to the assessment and coding of J1800 and J1900.
Section N: Medications – Drug Regimen Review Web-Based Training
The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of the Drug Regimen Review standardized patient assessment data elements (SPADEs) found in the Medications Section of the guidance manuals.
This 45-minute course is intended for providers in Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs), and is designed to be used on demand anywhere you can access a browser.
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SNF QRP FAQs
An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in Fiscal Year (FY) 2021 and other useful resources available to providers.
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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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