Volume #1-2019 | January 2019
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Cabinet for Health & Family Services
Office of Inspector General
Division of Health Care

Long Term Care Provider Newsletter
January 2019

All Cause Harm Prevention in Nursing Homes:
Applying Strategies from the New CMS Change Package

Date: Thursday, January 24, 2019
Time: 3:00pm - 4:00pm ET
Location: WebEx

One-third of SNF residents experience an adverse or temporary harm event, and the majority of those are preventable. As part of CMS’s focus on raising awareness of nursing home safety and to support safer nursing home care across the nation, CMS and the Quality Innovation Network National Coordinating Center released a new resource: a Change Package to prevent all cause harm in nursing homes. The Change Package is a compendium of successful practices of high-performing nursing homes, illustrating how they prevent harm while honoring each resident’s rights and preferences.

Please join us to learn more about the development of the Change Package and how you can use it to improve the quality of life and quality of care for those living in nursing homes and other long-term care settings. 

REGISTER for the event. GET the Change Package.
How to Have the Difficult Discussions About the End of Life

Date:   Tuesday, Feb. 12, 2019
Time:   11 a.m. CT/12 p.m. ET
Duration:   1 hour

Decisions about end-of-life care are deeply personal and often based on a person's values and beliefs. Talking with loved ones and healthcare providers is an important step to making a person's wishes known. These conversations relieve loved ones and healthcare providers of the need to guess what a person wants when facing a healthcare crisis.

The Community Action Network (CAN) invites you to a panel discussion on initiating these difficult end-of-life conversations featuring experts and people with Medicare.

Who Should Attend
Physicians, nurse practitioners, physician assistants, nurses, nursing home staff, home health providers, patients, caregivers and advocates .

  • Describe and differentiate between palliative care and hospice care
  • Identify effective strategies related to end of life discussions and how to get the conversation started
  • Identify resources and materials used to facilitate communication regarding advance care planning that will ensure the patient’s wishes are followed
Patient-Driven Payment Model

Effective October 1, 2019, CMS will be using a new case-mix model for Medicare, the Patient-Driven Payment Model, which focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment.

CMS has set up a website of resources available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html . As we prepare for this change, additional training opportunities will be made available later this year.
Kentucky Annual Utilization Surveys

The Kentucky Annual Utilization Surveys were released on January 15, 2019. The required completion date is March 15, 2019. All licensed long term care facilities are required to report. These include Nursing Facility, Personal Care, Nursing Home, Alzheimer, Intermediate Care and ICF/IID beds. The reporting of this data is required by 902 KAR 20:008 and 900 KAR 5:020. 

Any request for an extension of the deadline must go through Elizabeth Tutt, Survey Administrator and Healthcare Data Analyst. You may contact her by email or by calling (502) 564-9592 x.3156.

CLICK HERE for the website for the survey completion. The facility license number is the login and facilities should create their own password the first time they log in each year.
UK College of Nursing SRNA Training Program

Click HERE for the brochure or visit www.ukconce.org
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:
Chrystal Daugherty, IDR/IIDR Coordinator
Office of Inspector General
116 Commerce Ave.
London, KY 40744
Fax: (606) 330-2054
Improve Quality Measures for Pressure Ulcers and Other Wounds and Earn FREE CE Credits for LTC Nurses, Social Workers, Dietitians/Nutritionists

Access the newest AMDA Clinical Practice Guideline on Pressure Ulcers and Other Wounds as part of the Kentucky initiative to prevent pressure ulcers! Staff can earn FREE CE/CPE hours by completing the exam for nurses, social workers, and dietitians/nutritionists. Other staff can earn a Certificate of Completion! 

Access the other FREE training resources at the password-protected website www.cpgltc.org
with the CMS Region IV Quality Improvement Initiative, a 6-state CMS CMP program. 

  • 20 CE Exams with 1-3 contact hours – up to 42 total hours for LTC Nurses
  • 15 CE Exams with 1-3 contact hours – up to 29 NASW approved hours for LTC Social Work
  • 14 CE Exams with 1-3 contact hours – up to 20.5 hours for LTC Dietitians/Nutritionists from Becky Dorner Associates
  • CPG Implementation Series (Heart Failure, Pain Management, Urinary Incontinence) with accompanying training resources including narrated Power Points for nurses and nurse aides
  • 4-part Disease Awareness Video Series (COPD, Diabetes, Pain Management, Moderate Alzheimer’s)
  • Know-it-All™ Before You Call (for LTC staff) data collection tools for 70+ common health conditions
  • Know-it-All™ When You’re Called (for physicians and practitioners) data collection tools for 70+ common health conditions

LTC administrators receive facility-specific passwords and usernames. Please share with staff for access to FREE training materials at www.cpgltc.org. For facility username and password assistance, contact help@cpgltc.org
The next level of FREE Emergency Preparedness training conferences,  EP 201, will be held on February 20-21, 2019, at Berea College, and on April 16-17 at the Crowne Plaza Hotel in Louisville, Kentucky. This conference is a “Deep Dive” into the elements of the CMS Final Rule on  Evacuation, Transportation and Surge Planning. A preview of the new Electronic Hazard Identification mapping tool, created by Stantec, will be showcased at the conference. Learn how to conduct both Community and Tabletop Exercises.  Bring your facility floor plans to create a Surge Plan specifically for your facility. Network with other facilities in your region. 

All Leadership Teams such as Administrators, Assistant Administrators, Directors of Nursing, Maintenance/Plan/Facility Directors, Risk Managers and members of Safety/Emergency Preparedness Committees are invited to attend. There is no limit on the number of representatives from your facility who can attend.

Click here for a registration brochure. Please complete one registration form for each member attending the EP 201 conference and return by email to  ltc2prep@louisville.edu or by fax to 502-852-5887.

Questions? Contact Diana Jester at 502-852-3487 or diana.jester@louisville.edu.
Updates to MDS 3.0 Technical Information

Please visit the MDS Technical website to review the updates listed below.

January 9, 2019
An updated errata (V2.02.4) was posted for the FINAL version (v2.02.1) of the MDS 3.0 Data Specifications, which went into effect on October 1, 2018. Several additional items were mapped to edit -3897, and edit -3907 was discontinued. Note that these changes are already in production for ASAP, jRAVEN, and the VUT.
January 7, 2019
Data Collection Software: jRAVEN
The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect and maintain MDS Assessment data for subsequent submission to the appropriate state and/or national data repository. jRAVEN displays the MDS Item Sets similar to the paper version of the forms. Please consult the jRAVEN Installation and User Guides for additional information.
jRAVEN v1.6.1 is now available for download under the related links section at the bottom of the MDS Technical website . Users do not need a previous version of jRAVEN to download, install or use jRAVEN v1.6.1.
jRAVEN v1.6.1 includes the following enhancements:

  • VUT Version V2.2.2
  • Data Spec Errata V2.02.4 – to v2.02.1 of the Data Specs for MDS 3.0
  • Windows 10 software upgrade

For additional questions related to jRAVEN or technical support please contact the QTSO Help Desk by calling 800-339-9313 or by email to help@qtso.com .
January 3, 2019
A new DRAFT version of the 2019 MDS item sets (v1.17.0) has been posted. This version is scheduled to become effective October 1, 2019. The files are located in the Downloads section at the bottom of the MDS Technical website .
Smoke-Free Policies and Long-Term Care Study

You are invited to take part in a research study to help researchers at the University of Kentucky learn more about tobacco policies in the long-term care facility where you work. The research study is voluntary and it is up to you if you want to participate.

The researchers will ask you to take a brief online or phone survey. All responses will be kept confidential. The information will be aggregated; individual facilities will not be identified.

If you are interested in taking part in the research study, please click  here to access the survey or contact:

Ellen J. Hahn, PhD, RN, FAAN
BREATHE, University of Kentucky College of Nursing
A Message from Kentucky's QIN-QIO
OIG is pleased to provide information from the CMS funded QSource and atom Alliance, the Quality Innovation Network (QIN) - Quality Improvement Organizations (QIOs) for Kentucky. 
Click the link below to read a message from Kentucky's QIN-QIO:

Kentucky's Top 10 Citations
for Nursing Homes

Chrystal Daugherty
MDS Assessment/Coding Issues
 606-330-2030 x.283 or  e-mail  
Rhonda Littleton-Roe  
Transmission or Technical
502-564-7963 x.3300 or   e-mail
ePOC Accounts
Is your certified nursing facility signed up for ePOC? If so, be diligent about keeping your account and password up to date.  Click here  for the CMS security rules.

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 .
Have you notified your residents?

Click the link below to download and/or print the contact list for various agencies.

to find an Ombudsman

Which Enforcement Branch
is Serving You? 
To provide the highest level of service, the Division of Health Care operates through four regional offices. Knowing the appropriate Enforcement 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 Adam M. Meier, 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. 
ISTW: Integrated Surveyor Training Website

This CMS website provides training information to include the preceptor manual, the State Operations Manual and other documents. As always, the survey and certification process is a collaborative effort between CMS and providers. This website will allow providers the opportunity to take the same courses as surveyors.

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 

V acant
Deputy Inspector General 


Assistant Director 
Assistant Director
Assistant Director
Pharmacy Consultant
Commonwealth of Kentucky | Office of Inspector General | 275 East Main St., Frankfort, KY 40621