Issue#10-2013October 2013
Office of Inspector General 
Division of Health Care
OIG Banner
Office of Inspector General Home Page

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


Basic Chart

Health Care


Life Safety Code


CMS 5-STAR Results





September Results


3 Year Report

Learn more about the 5-STAR program by clicking 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 Survey and Certification Group

Surveyor Training Website

Click to Enter

The survey and certification process is a collaborative effort between CMS and providers.  CMS wants providers to understand the purpose and process of survey and certification to ensure Medicare and Medicaid beneficiaries receive quality health care. This website will allow providers the opportunity to take the same courses as surveyors. 


@ttention Providers

E-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.





 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 


Welcome to the Office of Inspector General, Division of Health Care's October 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.
Inspector General Accepts New Position


Effective October 16, 2013, Mary Begley assumed a new position, Commissioner of the Department for Behavioral Health, Developmental and Intellectual Disabilities.  Mary has successfully served as Inspector General since 2010 and will be greatly missed.  We wish her the best as she continues to serve the Cabinet in this new role.


Acting Executive Director Appointed
Connie Payne has been appointed as Acting Executive Director of the Office of Inspector General. A registered nurse, Connie has served in various roles with the Office of Inspector General since 1996, including the Director of the Division of Health Care. We welcome Connie to her new role as she continues to diligently serve the Office of Inspector General.
If you've worked in the long-term care industry, no doubt you're familiar with the term "culture change". The Pioneer Network defines culture change as "the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected". Core person-directed values are choice, dignity, respect, self-determination and purposeful living.


For some, the idea of culture change may seem overwhelming. Culture change within a long-term care setting can begin with the smallest changes. Dining choices and consistent staffing are common first steps in the transformation. To truly embrace the concept of culture change, it is important that each employee of a facility understand the reason behind the thought process and why it is important. This will lead to better outcomes for the residents, family members, and long-term care staff.

There are a variety of resources available to long-term care providers relative to culture change. The Centers for Medicare & Medicaid Services (CMS) has issued guidance to states and regions specific to culture change in the form of a Survey and Certification memo. View Memo
MDS/RAI Updates


jRAVEN (Resident Assessment Validation and Entry) 1.1.8 is a Java-based application that allows facilities to collect and maintain facility, resident, and assessment information for subsequent submission to the CMS data repository.  This free software is provided by CMS.  Consult the jRAVEN Installation Guide and jRAVEN User Guide for further information.


The jRAVEN 1.1.8 update to jRAVEN 1.1.7 includes the following:

  • Follows data spec version 1.13.2 implemented on October 1, 2013
  • Section S changes for states IL, MD, MA
  • Assessment Data Entry Report By Last Name adjustments
  • Automatic Resident Information updates for non-exported assessments
  • SRS-defined criteria for handling Duplicate Facilities
  • Assessment Data Entry Report By Status adjustments
  • FAC ID changes will be reflected in the output XML
  • Terminated User ID Assessment handling
  • Numerous item changes, with edits
  • User Tool reports' adherence to uniform guidelines
  • Updates to the user manuals to reference latest version  


MDS 2.0 Submission System Reminder

Effective October 1, 2013, the MDS 2.0 Submission system will no longer be available.


On October 1, 2013, users will notice the following changes on the State Welcome pages:

  • The MDS 2.0 Submissions link will be removed.
  • An MDS State Reports link will be added:
  • This new link will be available only for those states that currently have subdirectories for state-specific reports.
  • Selection of this link will allow users to access a list of state-specific reports.

NOTE:  MDS 2.0 Final Validation Reports will be available for 60 days after the MDS 2.0 record was submitted.  Users should select the Receive Validation Reports link to access these reports.



MDS 3.0 Assessment Submission and Processing (ASAP) System Enhancements

Please ensure that your MDS Coordinators and your software vendor are aware of the enhancements.  Read More 



RAI Manual posted!!

The Long-Term Care Facility Resident Assessment Instrument User's Manual, V1.11 (RAI User's Manual, V1.11) and change tables are publicly available at the following link:  MDS 3.0 RAI Manual.  Check the Downloads section.  This manual is effective 10/01/2013.  



MDS/RAI Coordinator Contact Information

For MDS assessment or coding issues, please contact Jan Keeling at 502-564-7963, x3301 or

via e-mail.  Continue to contact Rhonda Littleton-Roe at 502-564-7963, x3300 or via e-mail for any transmission or technical issues.

cms logo  

Survey and Certification Letters


This section is dedicated to providing the most recent 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 S&C letters may impact your facility.

Below is the S&C memo issued since the last newsletter: 


Cardiopulmonary Resuscitation (CPR) in Nursing Homes  



Cabinet for Health Services

Office of Inspector General

Division of Health Care



Leadership Team: 


Connie Payne, Acting Executive Director


Unbridled Spirit  
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 Jami Biggs.