Issue#4-2014April 2014
Office of Inspector General 
Division of Health Care
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Office of Inspector General Home Page


April 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  


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


Basic Chart

Health Care


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. 



Survey and Certification Letters

 Life Safety Code


Life Safety Code

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.   
To provide this important information, please contact
(502) 564-7963. 


Division of Health Care Leadership Team


Connie Payne

Acting Executive Director


Jackie Aitkin

Assistant Director 


Melanie Poynter

Assistant Director


Andrea Willhite

Assistant Director


Dudley Ellis

Pharmacy Consultant 






Long Term Care Provider Newsletter
Welcome to the Office of Inspector General, Division of Health Care's April 2014 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.  They may continue receiving this newsletter by joining our mailing list using the link at the bottom. We look forward to serving you through this communication vehicle.
What is QAPI?


We have heard a lot about QAPI, but what is QAPI all about?  QAPI is the facility's Quality Assurance and Performance Improvement program.


Your QAPI program should consist of these five (5) elements:

The above information was taken from the Centers for Medicare and Medicaid Services QAPI website.  Additional guidance and tools to assist you with your QAPI Program can be obtained from Survey and Certification letter, date June 7, 2013, S&C:13-37-NH 

SRNA Infection Prevention & Control
Final Training Session - Register Today
The Office of Inspector General, in collaboration with the Department for Medicaid Services and the Department for Public Health, is offering a free day long educational training for SRNAs on Communication and Interpersonal Skills, Concepts of Infection Prevention and Control in LTC settings, and Abuse Prevention and Reporting. 
Infections are a significant cause of illness, disease, and death for residents that live in long-term care (LTC) facilities. The LTC resident is more at risk of developing infections because of multiple underlying diseases, increased complexity of medical and care needs, changes in the immune systems and use of medications that reduce resistance to microorganisms, and increasing exposure to devices and antibiotics used to treat symptoms.  Nurse aides are an integral part of reducing the risk of Infections and should understand how to implement appropriate infection prevention and control policies and procedures within the LTC setting. This session will teach Nurse Aides what infection control means, the chain of prevention and how it applies to LTC, hand hygiene, standard and transmission based precautions, as well as use of personal protective equipment (PPE).


Please join us on Thursday, May 1, 2014 at KY Dam Village State Park for the final training session.  We are recommending at least two (2) SRNAs per facility attend the training.  Additional SRNAs, Infection Control Staff and Staff Development Coordinators are also welcome to attend.  Everyone attending the training will need an account on the KY TRAIN website and will need to register individually in order to receive credit for attending.  For details regarding registration and overnight accomodations, please see the Training Brochure or contact Jessica Lowe via email or at 502-564-7963 ext. 3310 for further assistance.

 Hand in Hand for Nursing Homes


The CMS Hand in Hand Toolkit is a high quality training series for nursing homes that emphasizes person-centered care for persons with dementia, as well as the prevention of abuse. 


Section 6121 of the Affordable Care Act requires CMS to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS, supported by a team of instructional designers and subject matter experts, created Hand in Hand to address the annual requirement for nurse aide training on these important topics.


CMS's mission is to provide nursing homes with one option for a high-quality program that emphasizes person-centered care for persons with dementia and also addresses prevention of abuse. Person-centered care is about seeing the person first, not as a task to be accomplished or a condition to be managed. It is the fulfillment of the Nursing Home Reform Law to consider each resident's individual preferences, needs, strengths, and lifestyle in order to provide the optimum quality of care and quality of life for each person.


Click here for information on how to obtain training materials.
Infection Prevention Training

North Carolina presents Gowns and Gloves, a free, on-line infection prevention training for all nursing home staff.  The four engaging modules are available online and are designed to make an impact on infection control in your facility.


Click here or visit the website for more information. 

Notice:  Five Star Preview Reports

just starts

The Five Star Preview Reports were made available on April 11th. To access these reports, select the CASPER Reporting link located at the top of your MDS State Welcome page. Once in the CASPER Reporting system, click on the 'Folders' button and access the Five Star Report in your 'KY LTC facid' folder. 


Nursing Home Compare updated with March's Five Star data on April 17, 2014.


Important Note: Provider preview reports will continue to be available on a monthly basis in advance of public posting and will include the dates and hours of the 5 Star Help line (800-839-9290) availability. is an alternative communication medium to direct inquiries.

MDS/RAI Updates

MDS 3.0 Error Spotlight 


1007 Fatal


Duplicate Assessment



The submitted MDS record is a duplicate of a previously submitted record for this resident. 



Determine why this record was submitted multiple times.  If you are not aware that it was already transmitted, check recent validation reports.  DO NOT resubmit this record as it is already in the database.



CMSNet Juniper Client Upgrade


During the April downtime, the CMSNet Juniper client was upgraded to resolve any potential vulnerabilities related to the Heartbleed virus. This upgrade prompts an upgrade of the Juniper client.  In most cases, the upgrade occurs without issue; but in some cases, we have found that the user must have admin privileges on the workstation to do the installation. Users who aren't prompted to upgrade and can't connect can click on the other side of the map and it will prompt for the upgrade. If you have any questions concerning this information, please contact the QTSO Help Desk at  or 1 (888) 477-7876.



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. 

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.