Office of Inspector General, Division of Health Care Newsletter


OIG Banner   


Want to Know Kentucky's Top 10   Citations for Nursing Homes?

Basic Chart

Health Care


Life Safety Code



CMS 5-STAR Results


Febuary 2013 Results

To learn more about the 5-STAR program click the link ==>  Overview of CMS 5-STAR System  


CMS Announces Updated, Enhanced Tools for Patients to Compare Nursing Homes.  click link for details ==> Nursing Home Compare Updates  



Life Safety Code


OIG Welcomes New Assistant Director

Melanie Poynter 
 Melanie Poynter has joined the OIG/Health Care team, as an Assistant Director. Melanie will be overseeing the Non-LTC levels of care.





 Quick Links

Office of Inspector General Website

Survey & Certification Letters


Long Term Care Inspection Findings


Long Term Care Newsletter Archives  


CMS Appendix Q - Guidelines for Determining Immediate Jeopardy


 CMS Appendix P - Survey Protocol for Long Term Care Facilities  


CMS Interpretive Guidelines for Nursing Homes

Kentucky Board of Licensure for Nursing Home Administrators


Long Term Care Regulations and Statutes


OIG Life Safety Code Portal 



 Cabinet for Health and Family Services, Office of Inspector General, Division of Health Care Leadership Team 

* Mary Reinle Begley, Inspector General




Join Our List

Join Our Mailing List

Unbridled Spirit




Issue: #02-2013  

    February 2013

Welcome to the Office of Inspector General, Division of Health Care's 
February  2013 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.
Below are the S&C memos for this month
  • Quality Assurance and Performance Improvement (QAPI) Guide - 13-05 NH - Preview of Nursing Home QAPI materials: The Centers for Medicare & Medicaid Services (CMS) will make a core set of introductory materials available on the CMS QAPI website by February 2013. Prior to that release, CMS is making QAPI at a Glance available in draft form for advance previewing by Quality Improvement Organizations (QIOs), State Survey Agencies, and Regional Offices; * QAPI at a Glance: QAPI at a Glance is a step-by-step guide that provides tools and resources to help nursing homes establish a foundation for QAPI; * ACA Provision: Section 6102(c) of the Affordable Care Act directs the Secretary to provide technical assistance and promulgate regulations for each nursing home to implement a QAPI system, and permits the Secretary to sequence these actions so the technical assistance is available prior to the regulations.


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

TB Screening in Health Facilities
TB TestBlood Assay for Mycobacterium Tuberculosis in Lieu of Skin Tests


While a Blood Assay for Mycobacterium tuberculosis (BAMT) is not currently listed as a TB screening option in the OIG's licensure regulations, effective February 19, 2013, the OIG will not cite any facility for a deficiency if the facility elects to use BAMTs in lieu of skin tests for TB screening.  Click the link to view the letter ==> TB Information Letter   


Run Away From IJ
What are the Trends - Knowing What to Avoid!

The Centers for Medicare & Medicaid Services (CMS) defines Immediate Jeopardy (IJ) as "a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." (See 42 CFR Part 489.3.)  In an effort to increase awareness regarding this most serious type of deficiency, the OIG has reviewed IJ trends over the last fiscal year and has identified the most commonly cited tags. 


==>  Click Here to find out and avoid IJs at your facility!

MDS Matters! - Security Change
CMS Banner TextSecurity Change for CMSNet Users!

A security change that may impact users connecting to CMS via CMSNet will be implemented on March 29, 2013. This change is required to comply with CMS security policies and will further secure users' data and systems from outside threats while their computers are connected to CMS.


 The change may affect the way users perform the file submission process and print reports. You will no longer be able to access the internet, network printers, or network folders while connected to CMS via CMSNet. Details regarding what steps can be taken to work around this security change are available at


Users interested in retaining the ability to access their network printers or folders might want to look for CMS-approved vendors who can provide this service. Information regarding approved Gateway Service Providers is available on the CMS website at


Off Label Anti-Psychotics
  Health Care Excel Logo
Health Care Excel (HCE), the Medicare Quality Improvement Organization (QIO) for the state of Kentucky, has collaborated with health care providers in our state for more than 20 years to improve residents' quality of care and quality of life.


HCE began planning a nursing home quality care collaborative (NHQCC) with 62 participating facilities.  Every facility will be looking closely at the off-label use of anti-psychotics for residents with dementia, plus education, sharing, and data collection for individualized care and falls.  As the Centers for Medicare & Medicaid Services (CMS) provides the Quality Assurance/Performance Improvement (QA/PI) change package, it will be incorporated into the Collaborative resources.  The kickoff NHQCC meeting is scheduled for Tuesday, March 19, 2013 at Paroquet Springs Conference Center in Shepherdsville, Kentucky.  Our guest presenters are Lisa O'Hara, a geriatric pharmacist, Barbara Frank and Cathie Brady, consultants with B & F Consulting.
Update: February 1, 2013 


During the past year and a half our goal at HCE has been...Click Here to Read More  
@ttention Providers!
E-mailE-mail Addresses Needed

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!




The Kentucky Department of Public Health would like to establish an email notification distribution group for Infection Preventionist (the person who is the leader for the Infection Control efforts at each facility) practicing in long-term care.  This email group would receive notifications concerning outbreaks, educational opportunities and pertinent State communications regarding infection prevention and control in the long-term care setting.  Names and e-mail addresses need to be sent to in Public Health.  Thank you.



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. 

If you would like more information, visit our website at
If you have an idea for a future article, e-mail Terri Cook at
Unbridled Spirit