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CMS 5-STAR Results



June 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

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 13-24-NH with Full Report: Report of the National Background Check Program Long-Term Care Criminal Convictions Work Group 
  • S&C 13-35-NH: Dementia Care in Nursing Homes
  • S&C 13-36-NH: Changes for Sub-Task 5E, Medication Pass Observation Protocol for LTC Facilities
  • S&C 13-37-NH: Rollout of Quality Assurance and Performance Improvement Materials for Nursing Homes

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 for 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.


Minimum Data Set (MDS) 3.0 Training
Two-day Training Tentatively Scheduled for August
More information regarding registration information and the exact location to follow in upcoming Newsletters.


If you have any questions about the training you may contact Jessica Lowe at 502-564-7963 at extension 3310 or at 





 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

Unbridled Spirit   
Issue: #06-2013  

                    June 2013

Welcome to the Office of Inspector General, Division of Health Care's June 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.
How Do You Solve a Problem Like Deficiencies?
 Guidelines for Submitting an Acceptable Plan of Correction (APoC)

Except in cases of past noncompliance, facilities having deficiencies (other than those at scope and severity of an A) must submit an APoC before substantial compliance can be determined. The APoC must be submitted to the State Survey Agency within ten (10) calendar days from the date the facility receives the CMS 2567 (the statement of deficiencies). An APoC must:

  • Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Include what corrective action was implemented for those residents; the date of implementation; and, who was responsible for making the corrections (title of position);
  • Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Include how the facility determined no other residents were affected by the deficient practice; the date this was determined; and, by whom;
  • Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Detail the actions taken (policy review/revisions and/or staff in-services, etc). Provide the dates of action and the titles of staff completing the action;
  • Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include the title of who will monitor the corrective action; how the actions will be monitored; when the monitoring will occur (frequency); and, how the results will be evaluated and by whom; and,
  • Include dates when corrective action will be completed. The date of compliance for the deficient practice cannot be a date on or prior to the survey exit date and cannot be a date when action is being taken by the facility. The corrective action completion dates must be acceptable to the State. If the plan of correction is unacceptable for any reason, the State will notify the facility in writing. If the plan of correction is acceptable, the State will notify the facility by phone, e-mail, etc. Facilities should be cautioned that they are ultimately accountable for their own compliance, and that responsibility is not alleviated in cases where notification about the acceptability of their plan of correction is not made timely.

The APoC will serve as the facility's allegation of compliance, and without it, the Centers for Medicare and Medicaid and/or the State Survey Agency have no basis on which to verify the facility's compliance.  


Reference Chapter 7; 7304.4 Acceptable Plan of Correction (Rev. 63, 09/10/10)

Advancing Excellence

in America's Nursing Homes

The Advancing Excellence in America's Nursing Homes Campaign is a major initiative of the Advancing Excellence in Long Term Care Collaborative. The Collaborative assists all stakeholders of long term care supports and services to achieve the highest practicable level of physical, mental, and psychosocial well-being for all individuals receiving long term care services.


The Mission of the Advancing Excellence in America's Nursing Homes Campaign is to help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America's nursing homes by:


Establishing and supporting an infrastructure of Local Area Networks for Excellence (LANEs), Strengthening the workforce, and Improving clinical and organizational outcomes.


Click here to read the whole article including how The Campaign works to achieve its mission and who The Campaign leaders include



MDS/RAI Updates
MDS 3.0 Provider Updates

'Discharge Assessments and the Use of Dashes'

Discharge Assessments and the Use of Dashes are addressed in the new MDS 3.0 Provider Update Training Series. This training series is the first web-based training offered in 2013 to providers addressing post-acute care topics.  More information can be found at the CMS Website.   


New Version of MDS Item Sets Posted

A new version (v1.11.1) of the MDS item sets has been posted on the MDS 3.0 Technical Information Web site.  This version is scheduled to become effective October 1, 2013 in conjunction with the new version of the data specs (v1.13.1).  The item sets should be considered provisional or draft and subject to change until final item sets are published. Click here to access this information.


QTSO User Guides Move

User guides previously located at the bottom of the MDS 3.0, MDS 2.0 Download pages of QTSO have been moved to a new page titled "User Guides & Training."

MDS 3.0 User Guides & Training Information

MDS 2.0 User Guides & Training Information


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.


Voluntary Termination

of the Medicare Provider Agreement


Dear Nursing Home Administrator,


Provisions specified in Section 6113 of the "Patient Protection and Affordable Care Act" (the Affordable Care Act) (Pub. L. 111-148) and amended sections 1128I and 1819 (h) of the Social Security Act require the nursing home administrator to notify the Secretary (CMS), the State Survey Agency (SSA), the State Medicaid Agency and the State Long Term Care (LTC) Ombudsman of the impending closure of a nursing home. The administrator is to provide notice a minimum of 60 days in advance of closure of the Skilled Nursing Facility (SNF) or Nursing Facility (NF). Advanced notification assures residents' living in our nation's nursing homes an opportunity to network with other prospective providers to locate quality health care services in a certified facility. Along with notice of closure, provide to CMS, the State and the LTC Ombudsman your facility's closure plan which provides for the orderly relocation of residents. The plan must be approved by the State Agency before closure of the nursing home. The intent of this document is to provide some of the minimum requirements that should be addressed in your relocation plan. Submit the closure plan and all related documents to the State Survey Agency. Your earnest cooperation in sharing information with the State Agency during the voluntary closure is appreciated.




Sandra M. Pace, ARA

Associate Regional Administrator

Division of Survey & Certification


Click here for the Full Disclosure Packet

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; and
  • 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 late August 2013.  This program will take place in Louisville, Kentucky.


Target Audience: Two individuals per facility- one person must be a member of the direct care staff (must be a SRNA/CNA) and one person from management.


More details with specific dates, training location, and registration information to follow in upcoming Newsletters.  



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

If you would like more information, please visit our website
If you have an idea for a future article, please contact Christina Libby.