Legal Memorandum: Auditing a Nursing Home's Files in KY

Issue: Are there guidelines, either mandatory or discretionary, for the auditing of the files in a nursing home in Kentucky?

Area of Law: Administrative Law, Administrative Law & Regulation (Federal and State), Healthcare & Pharmaceutical Law Compliance
Keywords: Nursing homes; Incident files; Audit
Jurisdiction: Kentucky
Cited Cases: None
Cited Statutes: Ky. Rev. Stat. § 216.530(1); Ky. Rev. Stat. §216.575
Date: 00/01/2008

Kentucky administrative regulations (902 Ky. Admin. Regs. 20:048, section 3(3)(d)) require nursing homes to make a “written report . . . of any incident or accident involving a patient (including medication errors or drug reactions), visitor or staff . . .”  The written reports are filed in an incident file.

Inspections of nursing homes and long-term care facilities in Kentucky are the responsibility of the Office of the Inspector General in the Cabinet for Health and Family Services.  Federal protocols*FN1 governing the inspection of nursing homes by state officials state that the inspection team shall ask for

Evidence that the facility, on a routine basis, monitors accidents and other incidents, records these in the clinical or other record; and has in place a system to prevent and/or minimize further accidents and incidents;


NOTE: At the discretion of the facility, this evidence could include or be a record of accident and incident reports.


U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services, State Operations Manual, Appendix P, online at http://cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf (accessed Aug. 21, 2008).

The regulations of the Cabinet for Health and Family Services that relate to audits and inspections adopt by reference several manuals of the Department of Medicaid Services, including two titled “Kentucky Medical Assistance Program Nursing Facility Services Manual" and the “Skilled Nursing Facilities Manual.”  906 Ky. Admin. Regs. 1:010, section 5.  Neither manual is available online,*