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CMS 5-STAR Results



Most Recent (April) Results

To learn more about the 5-STAR program click the link below 

Overview of CMS 5-STAR System  


CMS Announces Updated, Enhanced Tools for Patients to Compare Nursing Homes.  click link below for details

 Nursing Home Compare Updates  


Life Safety Code

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
  • S&C: 13-28- ICF/IID-QIDP Nomenclature ChangePursuant to Rosa's Law, the nomenclature for QMRP is changed to QIDP. Please ensure that all conversations, correspondence, and statements of deficiency use the correct nomenclature. 

Previous Survey & Certification Memos

CMS Survey and Certification Group

Announcing the CMS, Center for Clinical Standards and Quality, Survey and Certification Group training site. The CMS training website allows providers to take courses that surveyors take. 
@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.






 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 


CMS Surveyor/Provider Training 

 Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care


Leadership Team 

 Mary Reinle Begley, Inspector General

Issue: #05-2013  

                    May 2013

Welcome to the Office of Inspector General, Division of Health Care's 
May 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 at the bottom.  We look forward to serving you through this communication vehicle.

Sleep Tight

Medical Bed Mattress Care


From January 2011 to January 2013, the FDA received 458 reports associated with medical bed mattress covers failing to prevent blood and body fluids from leaking into the mattress (fluid ingress). 


RECOMMENDATIONS: The Safety Communication lists several recommendations for inspection and maintenance including:  
  • Regularly check each medical bed mattress cover for any visible signs of damage or wear such as cuts, tears, cracks, pinholes, snags or stains.
  • Routinely remove the medical bed mattress cover and check its inside surface. Once the mattress cover is removed, inspect the mattress for wet spots, staining, or signs of damage or wear. Check all sides and the bottom of the mattress.
  • Immediately replace any medical bed mattress cover with visible signs of damage or wear to reduce the risk of infection to patients.
  • DO NOT stick needles into a medical bed mattress through the mattress cover.
Refer to the Safety Communication for the complete list of recommendations.

Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program: 

MDS/RAI Updates
Updated MDS Manual Posted

The Long-Term Care Facility Resident Assessment Instrument User's Manual, V1.10 (RAI User's Manual, V1.10) and change tables are now publicly available on the CMS Website in the Downloads section.

MDS Test Submissions 

If MDS assessments are submitted as TEST in the ASAP system, they will be rejected beginning on Sept. 15th. The validation tool within RAVEN can be used for testing purposes.  

MDS 3.0 Training

Two day Training- Tentatively Scheduled for August 2013

The training will be held in Louisville, KY. More information on exact location and specific training dates to follow in upcoming Newsletters.

If you have any questions about the training you may contact Jessica Lowe at 502-564-7963 x3310 or via email.


MDS/RAI Coordinator Changes
For MDS assessment or coding issues, please contact Michelle Mitchell at 502-564-7963, x3304 or via e-mail. Michelle is graciously filling in until we refill this position of State MDS/RAI Coordinator. You can continue to contact Rhonda Littleton-Roe at 502-564-7963, x3300 or via email for any transmission or technical issues.


Free LTC Provider Training 

Tentatively Scheduled for August


 Dementia Beyond Drugs:

Changing the Culture of Care

Presenter: G. Allen Power, M.D.


Based on Dr. Power's award-winning book, this 2-day learning experience uses the framework of culture change to create a new approach to caring for people who live with dementia.


Learn why the current paradigm for dementia care can never produce satisfactory results and explore an experiential model that facilitates growth, meaningful engagement, and improved well-being via the application of person-directed care.


Participants will learn how to:

  • Identify the limitations of our current approach to care for those living with dementia;
  • Envision an "Experiential Model" for viewing dementia and recognizing the importance of enhancing well-being for all;
  • Apply the model to everyday situations and challenging behaviors, by using creative solutions to empower individuals to live full and positive lives.

The Office of Inspector General, Division of Health Care, Training Branch will offer a free educational opportunity for Long Term Care Providers to attend the "Dementia Beyond Drugs: Changing the Culture of Care" two-day training scheduled for August 2013.  This program will take place in Louisville, Kentucky. More details with specific dates and training location to follow in upcoming Newsletters. 

Enhanced Education of Infection Prevention in Nursing Homes
Module 1 is Here!

Enhanced Education of Infection Prevention in Nursing Homes is finally available! The first module, Antibiotic Resistant Organisms, launched on February 25th. A second module on Isolation Precautions will roll out in April. (read more)


Click on the Gowns and Gloves Logo (above) to find out more and register your nursing home for the Gowns and Gloves Infection Prevention Challenge!


Unbridled Spirit   

The Office of Inspector General is Kentucky's regulatory agency for licensing all health care, day care, and long-term care facilities as well as all 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 Christina Libby.