Issue#11-2013November 2013
Office of Inspector General 
Division of Health Care
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Want to Know Kentucky's Top 10 Citations for Nursing Homes?


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Health Care


Life Safety Code


CMS 5-STAR Results



September Results

October results have not been released by CMS.


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.  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

OIG Website

S & C Letters


LTC Inspection Findings


LTC 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


LTC Regulations and Statutes


OIG Life Safety Code Portal 


CMS Surveyor/Provider Training 





Long Term Care Newsletter

Welcome to the Office of Inspector General, Division of Health Care's November 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.
Making the Holidays Safe
The holiday season is fast approaching and with each passing day more and more  holiday decorations are being displayed. Trees, lights and other holiday decorations 
are a beautiful part of the season, but they can also create fire hazards. 
Because of the significant impact decorations have on flame spread, federal code and standards contain fairly stringent requirements intended to either inhibit their ignition or control the speed with which flame will travel across their surfaces.
Violations of this nature are cited on the CMS 2786R under K72 - Furnishings and Decorations and K73 Exits and Egress.  Refer to the S&C Memos listed below:
Keep this season magical for your healthcare facility by taking the necessary precautions and reviewing the above CMS S&C Memos and safety tips below. 
Insulin Administration - Update Guidelines

Upon reconsideration of the issues related to insulin administration in personal care homes, the Office of Inspector General hereby advises that the administration of routine doses of insulin may be delegated to unlicensed staff if the following guidelines are met.


Review Updated Guidelines 


These guidelines shall be effective immediately and remain in effect until further notice.  Compliance with these guidelines must begin immediately upon receipt of this letter.  

The Office of Inspector General anticipates that a standardized training for insulin administration by unlicensed staff may be available within three (3) to six (6) months from the date of this guidance.  Follow-up information regarding the anticipated training curriculum will be provided as it becomes available. 


If you have any questions regarding this matter, please contact the Division of Health Care at (502) 564-7963


MDS/RAI Updates
 maintenance 2
CMS will be completing some maintenance tasks on the MDS server on Friday, November 22, 2013.  When trying to connect to MDS submissions or CASPER reports on that day, you may need to use the following links during the maintenance timeframe.
  • The MDS submission webpage can be accessed by directly entering the address into your browser after connecting to CMSNet.


RAI Users' Manual Updates


The errata documents for the RAI User's Manual, Version 1.11 have been posted on the CMS MDS 3.0 RAI Manual webpage and are available at the following link: MDS 3.0 RAI Manual


Read More 



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 ASAP System Enhancements

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



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.

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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.

How Are We Doing?
We Want Your Feedback!
The LTC Newsletter was designed to provide you with current information that directly impacts you and your role in the LTC field.  This is your chance to let your voice be heard.  Please click on the link below and let us know how we are doing, what we can improve upon and provide suggestions for future articles.
Thank you in advance for sharing your thoughts with us.  We appreciate your time and suggestions.   

Division of Health Care



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.