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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
June 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 websites for the most up-to-date news and information:
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Root Cause Analysis - Part I of III
What is Root Cause Analysis (RCA)? During the next few months, we will review the steps to an effective RCA process. First, let us review the term Root Cause. The root cause is the core issue ”the highest-level cause” that sets in motion the entire cause-and-effect reaction that ultimately leads to the problem(s). Root Cause Analysis (RCA) is defined as a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems.
Examples of cause and effect… It rained heavily; consequently, the baseball game was cancelled. Mary studied hard for the algebra exam; therefore, she had a passing grade. Margaret made a big mistake, and as a result, she lost her job. Cause is the “why” something happened and effect is the “what” that happened. What about the root cause? It is deeper than just the cause. Sometimes it is the cause of the cause of the cause and you must ask “why” repeatedly to determine the root cause. Getting to the root cause of a problem usually cannot be done immediately after the effect has occurred. There is information to gather and analyze to get to the root of the problem.
The RCA process is essential for resolving problems at the core to ensure a solution and the problem does not recur. It is essential for an effective QAPI (Quality Assurance Performance Improvement) program to implement a robust RCA process to ensure the facility is providing quality care. RCA is a deep dive into a concern or problem that requires a team of people to analyze information to find a solution. Rarely can an RCA be done at the resident’s bedside or even in a morning meeting. Causative factors can be identified during a morning meeting or at the resident’s bedside, but the facility must analyze those causative factors to really get to the root of the problem.
The Centers for Medicare and Medicaid Services (CMS) has a tool available that provides a 7-step approach to investigating events that require a solution.
- Identify the event that needs to be investigated and gather preliminary information.
- Select a team facilitator and team members.
- Describe what happened.
- Identify the contributing factors.
- Identify the root cause or causes.
- Design and implement changes to eliminate the root causes.
- Measure the success of the changes.
In next month’s article, we will look closer at these seven steps and how to implement them.
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Q&A from your State RAI Coordinator
Can we be cited for using the Emergency Blanket Waiver which allowed providers flexibility in completing and transmitting assessments?
The Emergency Blanket Waivers that were issued due to COVID-19 Public Health Emergency (PHE) to allow providers flexibility in completing and transmitting assessments ended on May 10, 2021. What does that mean for us?
Answer: The Emergency Blanket Waivers were implemented to allow facilities to prioritize infection control efforts in response to the PHE. However, providers should only exercise the use of the waiver, if needed, due to circumstances related to the PHE and should not be cited for using the waiver.
Special Note: If the State Agency has evidence that the facility is no longer being impacted by the PHE, then they COULD be cited.
The Emergency Blanket Waiver for the MDS timeframe requirements in §483.20 ended on May 10, 2021. Facilities who are not in compliance with the MDS requirements on or after May 10, 2021, are NOT in compliance.
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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.
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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