Facility-Reported Incident Forms

The Centers for Medicare and Medicaid Services requires long-term care facilities to self-report incidents occurring in their facilities to the Office of Inspector General. For your convenience, fillable forms are available to promote continuity and consistency.

Two new Facility-Reported Incident forms have been released and are now posted HERE. They may be downloaded directly from the website.

Please use the new forms effective immediately. Remember, if there is insufficient space to complete an answer, additional pages may be attached.

Questions may be directed to your respective OIG Division of Health Care Branch Office.

Cold Weather Tips

• Have sprinkler system checked by professionals
• Insulate any water lines that run along exterior walls so your water supply will be less likely to freeze
• Caulk and weather-strip doors and windows
• Insulate walls and attic
• Install storm or thermal-pane windows or cover windows with plastic from the inside
• Repair roof leaks and cut away tree branches that could fall on your home or other structures during a storm
• Work with local emergency preparedness for contingency plans
• Turn the heat up to no less than 69 degrees
• Increase warm air circulation to uninsulated areas
• Provide additional maintenance to heating system to ensure it is running at an optimum level

MDS TRAINING NOW AVAILABLE

Minimum Data Set training, hosted annually by the Kentucky Office of Inspector General and presented by Myers and Stauffer LC, is now available in TRAIN. Each webinar in this "Back to the Basics" series covers a different chapter of the RAI Manual:

OIG DHC MDS RAI Manual Chapter 1 October 2023 1113709

OIG DHC MDS RAI Manual Chapter 2 October 2023 1113710

OIG DHC MDS RAI Manual Chapter 3 October 2023 1113711

OIG DHC MDS RAI Manual Chapter 4 October 2023 1113712

OIG DHC MDS RAI Manual Chapter 5 October 2023 1113713

OIG DHC MDS RAI Manual Chapter 6 October 2023 1113714

The Kentucky Board of Nursing has approved contact hours for Kentucky RNs and LPNs upon completion, assessment, and evaluation of some sessions. Kentucky LTC Administrators will also receive contact hours. (Please note that you must have an individual TRAIN account in order to receive credit.)

Please contact Darlene Cox with any questions by email or at 502-564-5805.

CMS Facility Questionnaire

Facility-Wide Wireless Internet

The Centers for Medicare & Medicaid Services (CMS) is interested in learning more about wireless internet access for residents within certified nursing facilities. If your facility does not have facility-wide wireless internet (Wi-Fi) for residents, please complete the questionnaire. CMS’ goal in collecting this information is to gain a better understanding of the barriers that exist to having facility-wide Wi-Fi internet availability to residents. Your response will help inform their efforts to make potential funding supports available to facilities in need.

Click here to access the questionnaire: Facility-Wide Wireless Internet Questionnaire

ATTENTION CERTIFIED NURSING FACILITIES: 

CMS Developed Global Public Health Emergency (PHE) Grants

Funds Still Available

CMS developed three applications to facilitate visitation and prevent the spread of COVID-19 infection. These one-time grants will continue beyond the PHE to allow all certified nursing facilities access to the products. CNFs can apply for all three programs for up to a total of $9,000.

Communicative Technology: Up to $3,000 for tablets and accessories to allow residents to communicate remotely with family and friends

Visitation I: Up to $3,000 for in-person visitation aids such as outdoor shelters and clear dividers

Visitation II: Up to $3,000 for portable fans and/or room air cleaners with HEPA filters (H-13, -14)

Want the funds but too busy for paperwork? We can help!

Contact Lena Mullins-Datko, CMP Grants Administrator, for assistance with applications at: Lena.mullinsdatko@ky.gov, CMPapplication_OIG@ky.gov, or (502) 564-5771

For more details on the Kentucky CMP Reinvestment Fund and applications visit the Civil Money Penalty Funds - Cabinet for Health and Family Services website or contact Lena Mullins-Datko.

Register for CMS’ 2023 CMS Health Equity Confidential

Feedback Reports Live Q&A

On November 16, 2023, at 2:00 p.m. ET, the Centers for Medicare & Medicaid Services (CMS) will host a live Q&A session regarding the Health Equity Confidential Feedback Reports released on October 16, 2023. The Q&A session will give participants an opportunity to ask and learn about answers to commonly asked questions regarding the report’s methodologies and interpretations from CMS subject matter experts.

Register for the live Q&A session HERE.

Already have questions about the Health Equity Confidential Feedback Reports? Please send questions to CMSHealthEquityCFRSession@ketchum.com by November 2, 2023, for potential inclusion in the Q&A session. Please note that CMS will answer as many questions as time permits and some questions will not be asked verbatim. CMS will post all questions and answers on each of the PAC Training & Education pages sometime after the webinar. 

Prepare for the Live Q&A Webinar:

To prepare for the November 16 live Q&A session, please review the October 16, 2023, Online Webinar recording, with slides, a transcript, and a Fact Sheet providing an overview of the Health Equity Confidential Feedback Reports available in the “Downloads” section on each of the following PAC Training & Education pages:

• Home Health Quality Reporting Training & Education webpage.
• Inpatient Rehabilitation Facility Quality Reporting Training & Education webpage.
• Long Term Care Hospital Quality Reporting Training & Education webpage.
• Skilled Nursing Facility Quality Reporting Training & Education webpage.

UPDATED: Final MDS 3.0 Item Sets version 1.18.11 v6

The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.18.11 have been updated and are now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. Changes in this version (listed below) align the item sets with the Errata V3.01.3 for MDS Data Specifications V3.01.1 (FINAL) posted September 21, 2023, on the Minimum Data Set (MDS) 3.0 Technical Information page. For a full list of changes to the final posted item sets since v1, see the Item Set Change Table Supplement that accompanies the posting. The MDS Item Sets v1.18.11 were effective beginning October 01, 2023.

M0300G1 on NPE

Replaced erroneous skip pattern <Skip to N2005, Medication Intervention> with the correct one: <Skip to N0415, High-Risk Drug Classes: Use and Indication>.

O0300A on NP and NQ

Corrected transposition of verbs in skip patterns (changed <Skip> to <Continue> in choice 0 and <Continue> to <Skip> in choice 1).

O0400 on NC and NQ

Removed completion language <Complete only when A0310B = 1 (complete O0400D2 when required by state)>.

O0400 on NP and SP

Removed completion language <Complete only when A0310B = 1>.

O0420 on NC, NP, and NQ

Removed completion language <Complete only when A0310B = 1>. 

Notice of Upcoming SNF QRP Measure Removals

The Centers for Medicare & Medicaid Services (CMS) is alerting Skilled Nursing Facility (SNF) providers of upcoming measure removals from the SNF Quality Reporting Program (QRP). The following quality measures are planned for removal from the iQIES Review and Correct Reports, Facility-Level Quality Measure (QM) Reports, and Resident-Level QM Reports in January 2024:

• Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
• Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
• Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients

Once removed from reports, users will no longer have access to any data or measure results for these measures.

These measures will last appear in the April 2024 Provider Preview Reports for the July 2024 Refresh of SNF QRP data. Starting with the October 2024 Release, these measures will be removed from Care Compare and Provider Data Catalog. Once removed, the historic publicly reported measure data will continue to be available in the Nursing Homes Including Rehab Services Data Archive files on the Provider Data Catalog.

Please direct any questions on these measure removals or questions related to quality measures on the SNF QRP Reports to the SNF QRP help desk at SNFQualityQuestions@cms.hhs.gov.

Care Compare October Release of SNF QRP Data – Now Available

The October 2023 release of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

For more information, please visit the SNF QRP Public Reporting website.

CMP Grant Program Resumes Accepting Applications

The Office of Inspector General has resumed accepting applications for the Kentucky Civil Money Penalty (CMP) Reinvestment Fund following receipt of updated guidance from CMS issued September 25, 2026.

CMP Reinvestment Fund*

OIG seeks innovative projects that support, protect, and benefit certified nursing facility residents. These initiatives must be outside the scope of normal facility operations and cannot be used to fund goods or services that the applicant already offers or is required to provide by state or federal law or regulation. There is currently no application deadline and applications can be submitted at any time.

For example:

a. A 1-year project to provide wound care training to direct care staff at 50 nursing homes is capped at a total of $250,000 (5,000 x 50 x 1 = 250,000)

b. A 3-year project to provide musical therapy to residents at 10 nursing homes is capped at a total of $150,000 (5,000 x 10 x 3 = 150,000)

CMS Developed Global Public Health Emergency (PHE) Grants

Formerly known as the COVID-19 Emergency CMP Grants, CMS is continuing the programs beyond the PHE to allow all Medicare and Medicaid participating nursing homes access to the products. CNFs can apply for one-time funding from each of the three programs for up to a total of $9,000 for the purchase of:

• Communication Technology: Tablets and accessories to allow residents to communicate remotely
• Visitation I: In-person visitation aids such as tents/outdoor shelters, and clear dividers
• Visitation II: Portable fans and/or portable room air cleaners with HEPA filters (H-13, -14)

For more information on the CMP Reinvestment Fund and the CMS Developed Global Public Health Emergency grants, as well as links to the updated forms, please view the attached KY CMP Information Brochure or visit Civil Money Penalty Funds - Cabinet for Health and Family Services (ky.gov).

For questions or assistance please contact Lena Mullins-Datko, Grants Administrator, at lena.mullinsdatko@ky.gov or CMPApplication_OIG@ky.gov. 

Kentucky's Top 10 Citations

for Nursing Homes

Health Care

Life Safety Code

Emergency Preparedness

Informal Appeal of Survey Findings

Every Long Term Care provider has the right to both an informal and formal appeal process following receipt of a completed Form CMS-2567. There are two informal appeal processes: Informal Dispute Resolution (IDR) and Independent IDR (IIDR).

Interested in Serving on an IDR Panel?

Kentucky requires one member of the IDR panel to be "a person currently engaged in the provision of Long Term Care services who has no affiliation with the provider disputing a deficiency." Typically, a Long Term Care Administrator is on each IDR panel. There is no payment or travel reimbursement for an Administrator serving on a panel. Administrators will be rotated. If a Long Term Care Administrator is interested in serving on a panel, a confidentiality statement must be signed prior to the participation in the first IDR panel.

Please complete the Confidentiality Agreement and submit via email, fax, or mail to:

Cabinet for Health and Family Services

Office of Inspector General

Division of Health Care 

DHC Leadership Team:

Adam Mather

Inspector General

Belinda Beard

Director

Marissia Izlar

Assistant Director

Andrea Willhite

Assistant Director