Kentucky Administrative Regulations
Title 906 - CABINET FOR HEALTH AND FAMILY SERVICES
Chapter 1 - Office of Inspector General
Section 906 KAR 1:120 - Informal dispute resolution
Universal Citation: 906 KY Admin Regs Service 1:120
Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO: 42 C.F.R. 488.301, 488.331
NECESSITY, FUNCTION, AND CONFORMITY: 42 C.F.R. 488.331 requires the cabinet to establish an informal dispute resolution process to be used by a provider to informally dispute a finding of deficiency at a nursing facility or skilled nursing facility. This administrative regulation establishes the informal dispute resolution process and expands the process to all long-term care facilities.
Section 1. Definitions.
(1) "CMS" means the Centers for
Medicare and Medicaid Services.
(2)
"Deficiency" means a failure to meet either a state licensure requirement or a
federal requirement for participation in the Medicare or Medicaid
Program.
(3) "Enforcement action"
means a remedy applied to effect prompt compliance by a provider with program
requirements.
(4) "IDR" means
informal dispute resolution.
(5)
"IDR coordinator" means a CMS-certified surveyor employed by the Office of
Inspector General, Division of Long-term Care, designated by the Director of
the Division of Long-term Care to serve as the IDR coordinator.
(6) "Immediate jeopardy" is defined in 42 C.F.R. 488.301.
(7) "Inspector
general" means the inspector general or his designee.
(8) "Plan of correction" means a description
of actions by a provider to correct a deficiency.
(9) "Provider" means a "long-term care
facility" as defined in KRS 216.510.
(10) "Scope and severity assessment" means
the letter designation assigned to a federal deficiency to represent the level
of:
(a) Actual or potential impact to resident
outcome; and
(b) Number of
residents affected.
(11)
"Statement of deficiencies" means the written notification to the provider
describing how the provider fails to meet regulatory requirements.
(12) "Substandard quality of care" is defined
in 42 C.F.R. 488.301.
Section 2. Request for Informal Dispute Resolution.
(1) A provider shall have one (1) opportunity
to informally dispute a cited deficiency or scope and severity assessment that
constitutes substandard quality of care or immediate jeopardy.
(2) The provider requesting an informal
dispute resolution shall select one (1) of the following appropriate formats:
(a) A desk review which shall be available
for a cited deficiency;
(b) A
telephone conference review which shall be available for a cited deficiency;
or
(c) A panel review which shall
be available for:
1. A cited deficiency with a
scope and severity assessment of G, H, I, J, K, or L;
2. A cited deficiency with a scope and
severity assessment that constitutes a substandard quality of care;
3. A cited deficiency that results in an
enforcement action by the Cabinet for Health Services;
4. A federal deficiency cited at the
condition level; or
5. A disputed
deficiency cited in conjunction with a deficiency qualifying for a panel
review.
(3) A
provider may request IDR upon receipt of the statement of
deficiencies.
(4) A request shall
be in writing and shall:
(a) Specify the
deficiency in dispute;
(b) Explain
and provide a detailed basis for the dispute; and
(c) Specify the format desired.
(5) Unless the provider requests a
five (5) calendar day extension pursuant to paragraph (c) of this subsection,
documentation in support of the provider's position shall be attached to the
request.
(a) A provider requesting a panel
review IDR shall submit five (5) copies of the required documentation and
shall:
1. Highlight or otherwise mark specific
information pertinent to the disputed deficiency; and
2. Annotate with the specific state licensure
deficiency or federal deficiency in dispute.
(b) A provider requesting a desk or telephone
conference review shall submit two (2) copies of the required documentation and
shall:
1. Highlight or otherwise mark specific
information pertinent to the disputed deficiency; and
2. Annotate with the specific state licensure
deficiency or federal deficiency in dispute.
(c) A provider may request an additional five
(5) calendar days to provide documentation in support of their position by
attaching a statement requesting the five (5) calendar day extension to the
request for IDR.
(d) Documentation
not submitted at the time of the request for IDR, or within a requested five
(5) calendar day extension, shall not be reviewed.
(6) The request and attachments shall be
delivered, on or before the mandated return date for the plan of correction, to
the IDR coordinator at the Office of Inspector General, Division of Long-term
Care, CHR Building, 275 East Main Street, 5E-A, Frankfort, Kentucky
40621.
(7) A request for IDR shall
not delay an enforcement action.
Section 3. Review Process.
(1) The IDR coordinator shall receive and
review each request for an IDR, and:
(a)
Conduct a desk review, if requested by the provider;
(b) Schedule a telephone conference review,
if appropriate and requested by the provider; or
(c) Schedule a panel review, if appropriate
and if requested by the provider.
(2) If a desk review is conducted the IDR
coordinator shall:
(a) Review documentation
submitted by the provider; and
(b)
Make a recommendation to the inspector general to:
1. Uphold the cited deficiency;
2. Modify the cited deficiency by deleting a
finding;
3. Modify the cited
deficiency by lowering the scope and severity determination;
4. Modify the cited deficiency by changing
the tag number; or
5. Delete the
cited deficiency.
(3) If a telephone conference review is
conducted, the IDR coordinator shall:
(a)
Review documentation submitted by the provider;
(b) Conduct a telephone conference call with
the provider to:
1. Receive verbal comments
relating to the disputed deficiency; and
2. Seek answers to questions relating to the
disputed deficiency; and
(c) Make a recommendation to the inspector
general to:
1. Uphold the cited
deficiency;
2. Modify the cited
deficiency by deleting a finding;
3. Modify the cited deficiency by lowering
the scope and severity determination;
4. Modify the cited deficiency by changing
the tag number; or
5. Delete the
cited deficiency.
(4) If a panel review is conducted:
(a) The panel shall consist of:
1. The IDR coordinator serving as a nonvoting
panel moderator;
2. Two (2) CMS
certified surveyors who:
a. Are employed by
the Office of Inspector General; and
b. Were not responsible for citing the
deficiency in dispute; and
3. A person currently engaged in the
provision of long-term care services who has no affiliation with the provider
disputing a deficiency.
(b) The members of the panel shall review
documentation submitted by the provider prior to the panel review
meeting;
(c) Unless the provider
requests and the IDR coordinator agree to an expanded time period, the panel
review meeting shall not exceed one (1) hour. The decision to expand the time
period for the IDR shall be based on the number and complexity of the
deficiencies to be disputed;
(d)
The provider may present additional oral information relating to the disputed
deficiency;
(e) A member of the
survey team responsible for citing the disputed deficiency may respond to the
information presented by the provider;
(f) A panel member may ask questions of
either the provider or the survey team member;
(g) A person presenting information to the
panel or answering questions of the panel may refer to relevant reference
materials
(h) The provider may
present an oral summary of its response to a disputed deficiency;
(i) After the panel review meeting has
concluded, the panel shall review all of the information presented relating to
the disputed deficiency;
(j) The
voting members of the panel shall make a recommendation to the inspector
general to:
1. Uphold the cited
deficiency;
2. Modify the cited
deficiency by deleting the finding;
3. Modify the cited deficiency by lowering
the scope and severity assessment;
4. Modify the cited deficiency by changing
the tag number; or
5. Delete the
cited deficiency.
(5) The inspector general shall make the
final determination to:
(a) Uphold the cited
deficiency;
(b) Modify the cited
deficiency by deleting the finding;
(c) Modify the cited deficiency by lowering
the scope and severity assessment;
(d) Modify the cited deficiency by changing
the tag number; or
(e) Delete the
cited deficiency.
(6) A
determination and the reasons supporting the determination made by the
inspector general as a result of the desk review, telephone conference, or
panel review IDR shall be mailed to the provider within thirty-five (35)
working days of receipt of a request for IDR.
(7) If the Inspector General makes a
determination that is different from the recommendation of the IDR coordinator
or the IDR panel:
(a) The notification
required by subsection (6) of this section shall also include the specific
reasons for the difference; and
(b)
The provider shall be given an opportunity for an in-person meeting with the
Inspector General to present documentation originally submitted to the IDR
Coordinator or the IDR panel and seek a reconsideration of the determination.
The meeting shall be conducted to allow sufficient time to ensure that a
reconsidered determination can be mailed to the provider within thirty-five
(35) working days of the receipt of the request for IDR.
(8) If a cited deficiency was modified as a
result of the informal dispute resolution process the provider may request the
Office of Inspector General, Division of Long-term Care to provide:
(a) A copy of the statement of deficiencies
indicating each modification by:
1. Striking
through deleted language; and
2.
Underlining new language; or
(b) A new statement of deficiencies
containing the modified deficiency. If a new statement of deficiencies is
issued the provider will be required to complete a new plan of
correction.
(9) If a
cited deficiency was deleted the provider may request the Office of Inspector
General, Division of Long-term Care to provide:
(a) A copy of the statement of deficiencies
indicating each deletion; or
(b) A
new statement of deficiencies absent the deleted deficiency. If the new
statement of deficiencies contains other cited deficiencies that were not
deleted the provider shall be required to complete a new plan of
correction.
STATUTORY AUTHORITY: KRS 194A.050(1), 42 C.F.R. 488.331
Disclaimer: These regulations may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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