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 and Family Services
Office of Inspector General
Division of Health Care
|
|
Long Term Care Provider Newsletter
April 2023
|
|
Duplicate MDS Assessments
During the year, the Office of Inspector General (OIG) may be contacted by our third party vendor, Myers & Stauffer (M&S), with a list of residents with duplicate MDS assessments in the CMS database. OIG staff review the list to find the discrepancies between the two assessments. These resident assessments may have a different first name, different name spelling, different birthdate or social, or multiple things that are different.
Once the discrepancy is found, OIG staff, usually the RAI/MDS Coordinator, contact the facility by phone and ask to speak with someone in the MDS department. The facility staff are advised that OIG is checking to see if the two residents are the same person or not. If both resident assessments belong to the same person/resident, the facility needs to advise OIG staff which information is correct. Once the correct information is obtained, OIG staff merge the incorrect assessments with the correct resident assessments.
If a facility is reluctant to give information concerning residents by phone, OIG staff will verify their identity by sending an email with identifying information. When reviewing a validation report and a facility finds a discrepancy, OIG can assist with reviewing the information for the resident by sending an email to jennifersmith@ky.gov.
Please do not include any identifying resident information in the email. OIG staff will contact the facility by phone to discuss the discrepancy and collect any resident information needed to resolve the issue.
|
|
Impacting Readmissions and Unnecessary Emergency Room Visits
Your Kentucky QIO, Alliant Health Solutions, has an opportunity being offered to nursing home providers across the state of Kentucky. Readmissions and unnecessary ED visits have been a challenge for providers like yourself, starting this spring, Alliant will be hosting a focused education series including best practice tools and resources to assist. We understand the current labor climates impact on your quality improvement projects. To assist with this, Alliant is offering a variety of methods to connect with you on this important measure including:
|
|
This opportunity affords you a mechanism to receive customized support from subject matter experts utilizing established best practices. Capture your experience as a Performance Improvement Project for QAPI and receive a Certificate of Completion for your records (Affinity and 1:1 support projects only).
|
|
NOW AVAILABLE: Final MDS 3.0 Item Sets version 1.18.11
|
|
NOW AVAILABLE: Draft MDS 3.0 RAI User’s Manual version 1.18.11
This version of the MDS 3.0 RAI Manual contains substantial revisions related to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires that standardized assessment items be collected across post-acute care (PAC) settings. Standardized data will enable cross-setting data collection, outcome comparison, exchangeability of data, and comparison of quality within and across PAC settings. Additionally, the language of the manual has been updated throughout to be gender neutral. Guidance and examples in numerous chapters and appendices have been revised for clarification and to reflect current regulations and best practices. Due to the scope of the revisions, CMS will not issue Replacement Pages for v1.18.11; those wishing to continue using a physical copy of the manual are encouraged to print the new version.
|
|
Care Compare April Refresh of SNF QRP Data – Now Available
|
|
SNF Provider Preview Reports – Now Available
The Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the July 2023 refresh.
|
|
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 2024 (CMS-1779-P)
On April 4, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1779-P) that provides updates to and proposals for the fiscal year (FY) 2024 Skilled Nursing Facility Quality Reporting Program (SNF QRP). This rule includes three new measure proposals, one measure modification proposal, and three measure removal proposals. The new measure proposals include the Discharge Function Score measure; the CoreQ: Short Stay Discharge Measure; and the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS is also proposing to modify the COVID-19 Vaccination Coverage among Healthcare Personnel measure to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest CDC guidance. In addition, CMS is proposing the removal of three measures including the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function; the Application of the IRF Functional Outcome Measures: Change in Self-Care Score for Medical Rehabilitation Patients measure; and the Application of the IRF Functional Outcome Measures: Change in Mobility Score for Medical Rehabilitation Patients measure. We are also proposing changes to the data completion thresholds for the Minimum Data Set data items and to begin the public reporting of the Transfer of Health Information to the Patient-Post-Acute Care and Transfer of Health Information to the Provider-PAC measures. Finally, we are seeking information on principles for selecting and prioritizing SNF QRP quality measures and concepts and providing an update on CMS continued efforts to close the health equity gap.
|
|
Getting to Know Eastern Branch
Nurse Consultant/Inspector Sue Hobbs
Sue graduated from Eastern Kentucky University in 1980 with an Associate Degree in Nursing. Since that time, she has worked in areas of Medical, Surgical, Trauma, Orthopedic and Pediatric Nursing, Same Day Surgery and Recovery Room. She also worked in Home Health, and Hospice making home visits and staffing as an office nurse for Oral Surgeons.
She also holds her Method of Instruction Certificate and was an adjunct instructor at Bluegrass Community College and a private school teaching classes for the Kentucky Medicaid Nurse Aide program for State Registered Nurse Aides. She has worked hard over the years being a voice and advocate for patients and residents, and loves serving the citizens of Kentucky.
Sue’s passion is her husband, two daughters and five grandchildren. She loves time gardening on her farm and any outside activity, with camping and hiking being at the top of the list.
|
|
CMP Grant Opportunities Available
CMP Reinvestment Fund
OIG seeks innovative projects that support, protect, and benefit certified nursing facility residents. These initiatives must be outside the scope of normal facility operations and cannot be used to fund goods or services that the applicant already offers or is required to provide by state or federal law or regulation.
- There is no minimum or maximum amount that can be applied for
- There is currently no application deadline and applications can be submitted at any time.
COVID-19 Emergency CMP Grants
The COVID-19 Emergency CMP Grants are temporary programs in place during the federal Public Health Emergency. Kentucky will continue to accept applications until CMS closes the programs. CNFs can apply for all three programs for up to a total of $9,000 for the purchase of:
- Communication devices and accessories to allow residents to communicate remotely
- In-person visitation aids such as tents/outdoor shelters, outdoor furniture, clear dividers, and more
- Portable fans and/or room air cleaners with HEPA filters (H-13, -14)
|
|
Ready to take your QAPI program to the next level? Registration is now open to Kentucky certified nursing homes interested in participating in this CMP Grant funded project which provides 12 hours of CE training, complimentary QAPI/PIP toolkits and Proactive consultation to support successful QAPI programming.
|
|
Division of Health Care Contact Information
Central Office
Belinda Beard, Director
Marissia Izlar, Assistant Director
275 E. Main St., 5E-A Frankfort, KY 40621
Phone: 502-564-7963
Fax: 502-564-6546
Western Enforcement Branch
Terri Gipson, Regional Program Manager
901 B South Main Street, Hopkinsville, KY 42240
Phone: 270-889-6052
Fax: 270-889-6089
Northern Enforcement Branch
Patricia Hinson, Regional Program Manager
L & N Building 10-W, 908 W. Broadway, Louisville, KY 40203
Phone: 502-595-4958
Fax: 502-595-4540
Southern Enforcement Branch
Tammy Ricks, Regional Program Manager
116 Commerce Ave., London, KY 40744
Phone: 606-330-2030
Fax: 606-330-2054
Eastern Enforcement Branch
Will Hendrickson, Human Services Program Branch Manager
455 Park Place, Suite 120A, Lexington, KY 40511
Phone: 859-246-2301
Fax: 859-246-2307
|
|
Kentucky's Top 10 Citations
for Nursing Homes
|
|
|
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.
|
|
Jennifer Smith, RN
RAI/Oasis/IDR-IIDR Coordinator
Office of Inspector General
Division of Health Care
275 E. Main St., 5E-A
Frankfort, KY 40621
Fax: (502) 564-6546
|
|
|
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.
|
|
|
All certified nursing facilities must sign up for ePOC. Please 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 yet signed up, see the Account Setup instructions.
|
|
Have you notified your residents?
Click the link below to download and/or print the contact list for various agencies.
|
|
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.
|
|
CMS Survey and Certification memoranda, guidance, clarifications and instructions to State Survey Agencies and CMS Regional Offices.
|
|
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:
|
|
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.
|
|
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.
|
|
|
|
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.
|
|
DHC Leadership Team:
Inspector General
Deputy Inspector General
Director
Assistant Director
|
|
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.
|
|
Commonwealth of Kentucky | Office of Inspector General | 275 East Main St., Frankfort, KY 40621 |
|
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.
|
|
|
|
|
|
|
