DOH/Provider Meeting Summary: May 2014

Nancy Leveille in Clinical & Quality

Below is the summary of the May 15, 2014 meeting:

1.    New DOH MDS Coordinator: DOH announced that Denise Dwyer has replaced Kathy Minnucci as the NYSDOH contact person for MDS issues. Her email address is:

2.    E-Prescribing: NYSHFA staff gave the group an update on their meeting with the Bureau of Narcotic Enforcement (BNE), Executive Secretary to the Board of Pharmacy, and the President of the Consultant Pharmacists on May, 6, 2014 related to the March, 2015 start date of e-prescribing. Issues NYSHFA brought forth on May 9th included the following:

  • The desire to improve care via e-prescribing and reduction of transcription errors
  • The disparity of computerization within SNF across the State
  •  Lack of funding for SNF to implement technology
  • The physician on call system in SNF and their ability to interface with EHR in the SNF
  • The legal ability for nurses to currently take verbal and telephone orders from Physicians, RNPs and PAs and have them cosigned within 48 hours without delay of delivery to the SNF and administration of those medications
  • Issues SNF already have with delay in delivery and administration of medications
  • Requesting a meeting with the BNE, providers from the SNF, Consultant pharmacists and the DOH SNF Surveillance and Quality staff to problem solve issues in the near future

The group agreed the next step was to establish a meeting with the BNE as described in the last bullet above.

3.    Sprinkler Update: DOH noted that CMS has provided some current documentation via S&C letter May 16, 2014 related to a need of some SNF to have a limited waiver for their sprinkler system. NYSHFA sent this info out to members in a separate topic in this May 22, 2014 edition. SNF must meet certain criteria to be eligible for waiver approval.

The group also requested that DOH and NYFD establish an easier system for documenting compliance of the NYC elevator shafts and electrical rooms sprinkler requirements using a non-water based solution. Currently the SNF must request a letter from NYFD to demonstrate this compliance, however, letters are not forthcoming from NYFD and SNF have no control over that process. DOH will evaluate the process.

4.    Essential Electrical Systems (EES): NYSHFA addressed the issue of deficiencies for K 146 being given out inconsistently in the Long Island region to SNF, who by the age of the building, should not have been included in this requirement. The new requirements for this specific issue in NFPA 99 relates to new construction and new equipment. DOH noted they are reviewing this issue but do not have a resolution at this point. We noted the increase in time it takes to get resolutions to life safety issues and the need for assistance.

5.    Special Focused Facilities (SFF): CMS has just updated the process for SFF. NYS will now only have 3 SFF at a time. This brings NYS back to its original number of 3 from a high of 5-7 over the last few years. Currently, there is a list of 25-30 SNF in NYS that CMS identifies as potential SFF. DOH must submit a list of 3 SNF from that list to CMS for their final approval by July 1, 2014. SFF will be surveyed 2 times in their first year with a 3rd survey by 18 months to evaluate sustainable compliance. If that is not evident, the SNF may go into Termination of their Medicare and Medicaid certification and thus need to close operations. Terry Baird, RN is DOH’s lead on this program.

6.    ADHC Immunization Report: DOH made it very clear that even though the ADHC programs did not need to report their data yet to DOH, they are still required to collect and file this information and be able to submit it to DOH upon request.

Masks are still required at this time due to an outbreak a couple weeks ago. NYSHFA will post as soon as this requirement is lifted.

7.    Update on the CMS focused survey pilots for MDS 3.0 and dementia care: DOH has not decided yet if they will go forward with these pilot projects, but if they do, they are leaning toward the dementia program vs. the MDS. Each pilot will have 5 SNF/5 states volunteer to participate.

8.    QIS update: DOH have distributed FY2014 1st 6 month report of deficiencies at a number of meetings recently. NYSHFA has identified variations across the state related to numbers and levels of deficiencies and see some patterns still there and a couple new ones emerging. NYSHFA’s Clinical and Quality Committee has been identifying these as well. We will follow-up with regional meetings with providers and DOH as needed. QIS surveys are only occurring in Western NY and the MARO region and Western having an average of 6.3 deficiencies whereby MARO is at 4. Capital and Central have had trained QIS staff leaving the department and, therefore, there is a need to reestablish their training. Capital will be getting updated training this summer and Central NY will begin the process in the fall. Michelle Louy is the new coordinator at DOH for this process and has been working out details for training with CMS. See attached QIS current information.

9.    Posting of SODs: NYSHFA discussed the issue of errors being made of posting SOD on the website prior to the conclusion of an IDR and appeal. DOH’s process is that an IDR needs to get into them by the 10th calendar date after receiving your SOD. Then DOH has till day 14 post SOD to enact a hold on posting your SNF survey results. If the 14 day target date is not achieved by DOH, then the first time a correction can be made is 30 days afterwards. NYSHFA requested that DOH review their process and identify how it might breakdown during day 10-14, because if the SNF does not get their IDR electronically sent to DOH by day 10, it doesn’t go forward, so the issue lies between day 10-14. IDRs and appeals have eliminated deficiencies and have reduced scope levels and therefore should not be posted to the internet until due process has occurred. NYSHFA strongly encourages members to check their SNF posting on a regular basis.

10.Emergency Prep: NYSHFA and HANYS are providing a free webinar on e-Finds on Tuesday May 20, 2014. Announcement have been out for a few weeks.

11.DSRIP: The group discussed the SNF role in DSRIP. NYSHFA has sent out numerous member mailings on this topic and soon will have an ICON on the front page of our website to consolidate all our information on this topic. DOH encourages SNF to participate as safety providers and collaborate with your local hospitals to have access to grant funds to reduce hospitalizations and medication errors across the continuum.


  NYSHFA CONTACT: Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20