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Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care

OIG Welcomes New Acting Inspector General

Tricia Steward has a bachelor’s degree in health sciences with a clinical and nutritional emphasis and a minor in sociology. For three years, she was a health educator for the Whitley and Knox County Health Departments. Ms. Steward started at OIG's Division of Health Care in 1988 as a dietetic inspector and was later promoted to regional program manager, where she served for 10 years until retiring in 2008. She spent a year as a contracted health care surveyor assisting providers with removal of immediate jeopardy. She spent the next 13+ years as a Federal Surveyor for a contract survey company, traveling the US while conducting state veteran home, VA medical center, community living center and Medicare and Medicaid Services standard, abbreviated, and focused infection control surveys. Of note, Ms. Steward has worked (surveyed) in every US state, including Alaska, Hawaii and Puerto Rico. Welcome aboard!

SNF Quality Reporting Program: Non-Compliance Notifications

The Centers for Medicare & Medicaid Services (CMS) is providing notifications to Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) Swing Beds (SBs) that were determined to be out of compliance with SNF Quality Reporting Program (QRP) requirements for calendar year (CY) 2023 which will affect their fiscal year (FY) 2025 Annual Payment Update (APU). Non-compliance notifications will be distributed by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ My Reports folders in the Internet Quality Improvement and Evaluation System (iQIES) on July 03, 2024. If you receive a letter of non-compliance, you may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 14, 2024. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification letter and on the SNF Quality Reporting Reconsideration and Exception & Extension webpage.

Please note: Any reconsideration containing protected health information (PHI) will not be processed. All PHI must be removed in order for a reconsideration to be reviewed.

MDS 3.0 QM User’s Manual Version 16.0

Risk Adjustment Appendix File

The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual v16.0 Risk Adjustment Appendix is now available. The Risk Adjustment Appendix File for the MDS 3.0 Quality Measures User’s Manual is a reference to be used in conjunction with the MDS 3.0 Quality Measures User’s Manual v16.0, and contains coefficient values used to calculate the risk-adjusted quality measures.

The latest coefficient values in this appendix file utilize assessment data received for 2024 Quarter 1, and reflect, where applicable, updates to the measure specifications for the risk-adjusted NHQI measures, effective October 1, 2023. 

For more information, please visit the NHQI Quality Measures website.

Free Training for Nursing Facility Staff

The Center of Excellence for Behavioral Health in Nursing Facilities (COE-NF) was established by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare and Medicaid Services (CMS). It provides mental health and substance use training, customized technical assistance and resources to certified Medicare and Medicaid nursing facility staff who care for residents with a variety of behavioral health conditions at absolutely no cost.

Check out resources today!

www.nursinghomebehavioralhealth.org

CMS Developed Global Public Health Emergency (PHE)

Grants Funds Still Available

CMS developed three applications to facilitate visitation and prevent the spread of COVID-19 infection. These one-time grants will continue beyond the PHE to allow all certified nursing facilities access to the products. CNFs can apply for all three programs for up to a total of $9,000.

Communicative Technology: Up to $3,000 for tablets and accessories to allow residents to communicate remotely with family and friends

Visitation I: Up to $3,000 for in-person visitation aids such as outdoor shelters and clear dividers

Visitation II: Up to $3,000 for portable fans and/or room air cleaners with HEPA filters (H-13, -14)

Want the funds but too busy for paperwork? We can help!

Contact Lena Mullins-Datko, CMP Grants Administrator, for assistance with applications at: Lena.mullinsdatko@ky.gov, CMPapplication_OIG@ky.gov, or (502) 564-5771.

For more details on the Kentucky CMP Reinvestment Fund and applications visit the Civil Money Penalty Funds - Cabinet for Health and Family Services website or contact Lena Mullins-Datko.

Division of Health Care Contact Information

Central Office

Carrie Storms, Director

Marissia Izlar, Assistant Director

Andrea Willhite, 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

Vacant, Human Services Program Branch Manager

901 B South Main Street, Hopkinsville, KY 42240

Phone: 270-889-6052

Fax: 270-889-6089

Northern Enforcement Branch

Chuck Ballou, Regional Program Manager

Carmen Ferguson, Human Services Program Branch 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

Casey Shelley, Human Services Program Branch Manager

116 Commerce Ave., London, KY 40744

Phone: 606-330-2030

Fax: 606-330-2054

Eastern Enforcement Branch

Gae Vanlandingham, Regional Program Manager

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

Health Care

Life Safety Code

Emergency Preparedness

Informal Appeal of Survey Findings

Every Long Term Care provider has the right to both an informal and formal appeal process following receipt of a completed Form CMS-2567. There are two informal appeal processes: Informal Dispute Resolution (IDR) and Independent IDR (IIDR).

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.

Please complete the Confidentiality Agreement and submit via email, fax, or mail to:

All certified nursing facilities are required to 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.

Click here for the CMS security rules.

If your facility is not yet 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 contact Zakary Carter, ASPEN Coordinator, at Zakary.Carter@ky.gov.

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.

Regional Map

Contact Information

LTC Facility Self-Reported

Incidents & Complaints

Email addresses were 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. 

Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care 

DHC Leadership Team:

Tricia Steward

Acting Inspector General

Carrie Storms

Director

Marissia Izlar

Assistant Director

Andrea Willhite

Assistant Director