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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
April 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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CMS Issues Changes to Visitation, Communal
Activities and Dining, and Testing
On April 27, 2021, CMS released changes to visitation, communal activities and dining, and testing based on COVID-19 vaccination status of staff and residents. Below are summaries of this guidance.
Summary of Changes to QSO 20-39-NH Nursing Home Visitation:
Core Principles of COVID-19 Infection Prevention/Indoor Visitation
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Face covering or mask and social distancing at least six feet between persons, in accordance with CDC guidance. Per CDC, “fully vaccinated residents” and visitors can choose to have close contact and not wear a face covering or mask while alone in the resident’s room or the designated visitation room. However, visitors should wear face covering or mask and physically distance from staff and other residents at all other times in the facility. “Not fully vaccinated” resident and visitor, a face covering or mask and social distancing should continue. However, “fully vaccinated residents” can choose to have close contact with their unvaccinated visitor while both continue to wear well-fitting facemasks.
Outdoor Visitation
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Added “quarantine status” to a resident’s health status as a hindrance to outdoor visits.
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Q&A from your State RAI Coordinator
The CDC has recommended that Covid-19 vaccines should be administered alone, with a minimum interval of 14 days before or after administration of any other vaccines.
In addition, the guidance should be coupled with a discussion with the resident’s physician, and the results of that discussion and decision should drive the coding of the MDS.
For the pneumococcal vaccine, there is no specific CDC guidance regarding COVID-19. However, like the influenza vaccine, a discussion with the resident’s physician would be prudent.
CMS expects the primary care physician to work with the facility staff and use CDC guidance to make sound clinical decisions on an individualized basis. This is especially true for considerations on whether or not to vaccinate a resident, as well as the best time for vaccination.
Current CDC guidance regarding influenza and routine vaccinations during the COVID-19 pandemic can be found HERE.
As always, the current coding guidance drives the MDS coding.
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NEW TRAINING AVAILABLE – Resident Mood Interview (PHQ-9©) for
the Skilled Nursing Facility (SNF) Setting Video Tutorial
The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial that depicts a scenario that demonstrates the interview of a resident and subsequent coding of D0200. Resident Mood Interview (PHQ-9©) and D0300. Total Severity Score. Various interviewing tips and techniques are highlighted in the video to promote accurate coding. The video tutorial is approximately 30 minutes in length and is designed to be used on demand anywhere you can access a browser.
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Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022 CMS-1746-P
On April 08, 2021 the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1746-P) that provides updates to and proposals for the fiscal year (FY) 2022 Skilled Nursing Facility Quality Reporting Program (SNF QRP). This rule includes two new measure proposals: the Skilled Nursing Facility (SNF) Healthcare-Associated Infections (HAI) Requiring Hospitalization Measure and the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) Measure as well as an update to the specifications for the Transfer of Health (TOH) Information to the Patient-Post-Acute Care Quality Measure. In addition, CMS is proposing a modification to public reporting for the SNF QRP quality measures in order to accommodate the exception of 2020 Q1 and Q2 data. Lastly, this proposed rule includes two Requests for Information (RFI) related to the use of Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Post-Acute Care Quality Reporting Programs as well as Closing the Health Equity Gap.
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LTC2Prepare Training: EP 301-Catastrophic Planning
Scheduled for June 22-23, 2021
Attend in-person or watch the live stream event
The EP301 – Catastrophic Planning conference is scheduled for June 22 and 23. The conference will be held at the University of Louisville Shelby Campus, Founders Union Building, in Louisville.
The EP 301 Conference will be held as an in-person conference and as a live stream event! Registration for this FREE conference will be available soon.
Topics will include: supporting staff resilience in the LTC setting 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.
This program will be submitted (but has not been approved) for Continuing Education for participants hours from NAB/NCERS. Call Diana Jester at 502/852-3487 for further information. This program will be submitted to the Kentucky Board of Nursing for Continuing Education through University of Louisville Hospital, provider number 4-0068-7-20-1141.
CEs will be available (when approved) 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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Java PDPM Grouper
A beta test version of the Java PDPM Grouper has been posted. This version is to allow users to familiarize themselves with the Java program. The Fiscal Year 2022 PDPM Grouper, v.2.0, will be distributed only in a Java version. These files are located in the Downloads section of the MDS 3.0 Technical Information website.
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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 & check to see if it passed quality assurance?
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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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