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Unbridled Spirit

Issue: #11-2012  

    November 2012

Welcome to the Office of Inspector General, Division of Health Care's 
November 2012 edition of the Long Term Care Provider Newsletter.  This newsletter is a valuable vehicle to update you on current events affecting Long Term Care.  

Please feel free to share this newsletter with anyone you think would benefit.  To continue receiving this newsletter, be sure to join our mailing list by clicking the link to the left of this article.  We look forward to serving you through this communication vehicle.


CMS Medicare News 

Recent Survey and Certification Letters


Below you'll find links to survey and certification letters issued by the Centers for Medicare and Medicaid Services (CMS) pertaining to Long Term Care facilities.  Please take a look and determine how these may impact your facility.
The following S&C memos were distributed this month:
  • Nursing Homes - Clarification of Guideance related to Medication Errors and Pharmacy Services - 13-02-NH - CMS is providing clarification on three specific topics related to medication errors and pharmacy services: * Medication Errors: Potential medication errors related to medication administration via feeding tube and administration timing for metered dose inhalers and proton pump inhibitors and survey implications. * Medication Administration Practices: The practice of "borrowing" medications and issues related to diversion, control, reconciliation and disposal of medications, including fentanyl patches. * Medication Regimen Reviews for Stays under 30 days and/or Changes in Condition: The need for pharmacist medication regimen reviews when a resident experiences a change in condition and/or for residents admitted for less than 30 days.


To view previous S&C Memos click the link ==>  Survey & Certification Memos

Falling For You!

Non-Compliance Related to Resident Falls in Nursing Homes


Across the Commonwealth, non-compliance related to resident falls in nursing facilities continues to be a concern. The Division of Health Care in the last quarter, July through September, identified deficient practice at F323 Accidents Man falling related to resident falls fifteen times. Of these deficiencies, three deficiencies were at a severity of actual harm and two were immediate jeopardy.


Historically, fall related deficiencies have been specific to facilities not ensuring care plan interventions were implemented and/or effective. The facilities had not ensured a thorough investigation was conducted to identify causal factors of the fall/incident. The facilities did not initiate their process/system to re-evaluate interventions, or develop and implement more effective interventions in order to prevent the recurrence of the fall. Additionally, those facilities with residents having repeated fall occurrence, through evidence of the survey(s), had not conducted a root cause analysis of the multiple falls i.e. track/trend data, review of investigations, interview of staff providing care, resident assessment and care plan implementation, review of the effectiveness of existing interventions, implementation of new interventions and follow-up to ensure new interventions were effective etc. Certified surveyors follow the federal regulation probes and investigative protocol validating whether an accident was avoidable through observation, interview and record review in order to determine compliance/non-compliance.


Below are copied portions of the Centers of Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP, F323 as it relates to falls. Please refer to the full regulation, interpretive guideline and investigative protocol as it relates to Accidents.


Click Here to Read More....

@ttention Providers!
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So that we may deliver the best customer service, please ensure that the Division of Health Care has up to date contact information for your facility, including e-mail addresses.  Please contact 502-564-7963 to provide this important information!


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The Office of Inspector General is Kentucky's regulatory agency for licensing all health care, day care and long-term care facilities and child adoption/child-placing agencies in the commonwealth. 

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If you have an idea for a future article, e-mail Terri Cook at
Unbridled Spirit