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Cabinet for Health and Family Services
Office of Inspector General
Division of Health Care
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Long Term Care Provider Newsletter
August 2021
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A Message from the Inspector General
Governor Beshear has proclaimed this week as Health Care Heroes Appreciation Week. On behalf of OIG, I would like to extend a very heartfelt thank you to the health care workers in the Commonwealth.
This pandemic continues to be a challenge lasting far longer than anyone had thought and I know that it has been exhausting and at times frustrating. I believe, like many of you, that this is a calling and it is not just a calling for the clinical staff, but also the dietary teams, the environmental teams, maintenance crews, and administrative support. It truly takes a village and you are all heroes elevating others' needs over your own.
Please take this week to appreciate just how special you and your colleagues are. I speak for all of OIG when I say we appreciate and value you. Thank you so much for all you have done and continue to do.
Adam Mather
Inspector General
**Please allow time for this large file to open. Any omissions or errors are on the part of the editor.
We received an overwhelming response and couldn't include all submissions.
All of the administrators said EVERYONE is a hero!
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Electronic Plan of Correction
for Certified Nursing Homes
The Electronic Plan of Correction (ePOC) application was initiated in Kentucky on June 1, 2016. The ePOC application eliminates the need for paper-based communication between Certified Nursing Home providers and the Office of Inspector General, Division of Health Care, when submitting and reviewing plans of correction. Once providers complete the ePOC enrollment process, they can begin accessing the CMS-2567 Statement of Deficiencies (SOD) and enter their Plan of Correction (POC) via the secure website created by CMS.
Kentucky currently has 162 certified nursing facilities utilizing ePOC. Participation was voluntary; however, our CMS Atlanta location has requested we no longer offer two options for submitting the POC. Therefore, it will be mandatory for all remaining Certified Nursing Homes to enroll in ePOC by January 1, 2022.
Instructions and training information links are available on the OIG website. Our staff will provide technical support to assist providers when needed to walk through process. The contact information is located in the ePOC Accounts section of this newsletter.
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Root Cause Analysis - Part III
This is the final article in the series related to Root Cause Analysis (RCA). Let’s wrap up these articles by talking about some ways to help you implement the Root Cause Analysis (RCA) Process. Let’s review the seven steps and add some tips for implementing each step…
Step 1 – Identify the event to be investigated and gather preliminary information
- Be sure to start with a problem and not the solution. It is tempting to assume we know what will fix the problem before we’ve thoroughly examined it. Assumptions are often wrong and may hinder complete analysis of the underlying causes.
- The problem statement should objectively state what went wrong, not why, or how. An example of an effective problem statement is, “Resident X continued to receive a medication one week after the order was given for discontinuation.” A good problem statement will facilitate a more thorough examination of the problem.
- If the event represents a liability concern or questionable practices by an employee, the leadership team can initiate a risk management review or an employee performance review to start simultaneous with, but separate, from the RCA process. The RCA process should focus on systems rather than individual performance.
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Free MDS Training Coming Soon!
Minimum Data Set training, hosted annually by the Kentucky Office of Inspector General and presented by Myers and Stauffer LC, is scheduled to be available October 2021 on TRAIN. This free course, split into six 90-minute webinars, will review the Resident Assessment Instrument Manual with an emphasis on PDPM items.
The Kentucky Board of Nursing has approved contact hours for Kentucky RNs and LPNs upon completion, assessment, and evaluation of each individual session. Kentucky LTC Administrators will also receive contact hours. (Please note that you must have an individual TRAIN account in order to receive credit.)
Stay tuned for further details, and please contact Melissa Richard with any questions by email or at 502-564-7963 x.3310. |
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How to Update Nursing Home (NH)/Skilled Nursing
Facility (SNF) Demographic Data
SNF Quality Reporting Program (QRP) quality data on Care Compare are updated on a quarterly basis.
The Centers for Medicare & Medicaid Services (CMS) will be transitioning to a new data source for providers’ demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities / Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs) and Hospices). These demographic data include such items as the provider name, provider-mailing address, provider physical address, State, ZIP Code, etc. These provider demographic data are displayed on the Provider and Quality Measure reports generated from the Quality Improvement and Evaluation System (QIES) Certification and Survey Provider Enhanced Reports (CASPER) Reporting application for SNF/NF and Hospice providers and reports generated from Internet Quality Improvement and Evaluation System (iQIES) for HHA, IRF, and LTCH providers. Additionally these same demographic data are displayed on the public reporting websites such as the Provider Data Catalog (PDC).
Historically provider demographic data have been maintained in the Automated Survey Processing Environment or ASPEN software; however, CMS will be transitioning to use the demographic information from Provider Enrollment, Chain and Ownership System (PECOS). While this transition is underway, a final date when all demographic data will be obtained from PECOS has not been identified. During this transition, all SNF/NF providers will be responsible to ensure their latest demographic data are updated and available in both the ASPEN and PECOS systems.
A referencing document that outlines the steps each PAC provider should follow can be accessed in the Downloads section of the NH/SNF Demographic webpage. Should you have questions regarding this updated process, please contact the iQIES help desk or by phone at (800) 339-9313.
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Section K: Height, Weight, and Nutritional Approaches for SNF Providers
The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of K0200: Height and Weight and K0500: Nutritional Approaches. This 30-minute course is intended for providers in Skilled Nursing Facilities (SNFs) and is designed to be used on demand anywhere you can access a browser. The course includes interactive exercises to test your knowledge related to the assessment and coding of K0200 and K0510.
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SNF Prospective Payment System: FY 2022 Final Rule
On July 29, CMS issued a final rule updating Medicare payment policies and rates for Skilled Nursing Facilities (SNFs) under the SNF Prospective Payment System (PPS) for Fiscal Year (FY) 2022. In addition, the final rule includes several policies that update the SNF Quality Reporting Program and the SNF Value-Based Program (VBP) for FY 2022.
CMS estimates that the aggregate impact of the payment policies in this final rule would result in an increase of approximately $410 million in Medicare Part A payments to SNFs in FY 2022. This estimate reflects a $411 million increase from the update to the payment rates of 1.2%, which is based on a 2.7% SNF market basket update, less a 0.8 percentage point forecast error adjustment and a 0.7 percentage point productivity adjustment, and a $1.2 million decrease due to the proposed reduction to the SNF PPS rates to account for the recent blood-clotting factors exclusion. These impact figures do not incorporate the SNF VBP reductions that are estimated to be $184.25 million in FY 2022.
The final rule also includes:
- Methodology for recalibrating the Patient Driven Payment Model (PDPM) parity adjustment
- Section 134 of the Consolidated Appropriations Act, 2021 – New Blood Clotting Factor Exclusion from SNF Consolidated Billing
- Changes in PDPM ICD-10 code mappings
More Information:
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SNF QRP Annual Update Table for Reporting Assessment-Based QM
and Standardized Patient Assessment Data Elements
Affecting FY 2023 Posted
An update to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Annual Payment Update (APU) Table for Reporting Assessment-Based quality measures (QMs) and standardized patient assessment data elements to CMS is now available. This document has been updated to reflect the data elements required to meet the APU minimum data completion threshold for FY 2023. Additionally, an update to the SNF QRP Data Collection and Final Submission Deadlines for the FY 2023 SNF QRP is available. This document has been updated to reflect the data collection and final submission deadlines required to meet the APU minimum data completion threshold for FY 2023.
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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
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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