DOH Dementia Care Program Pilot Survey

Nancy Leveille and Karen Morris in Clinical & Quality

As reported in the July DOH/Provider meeting minutes, CMS via DOH will be piloting a dementia survey in 5 SNF across NYS between now and September. It will be a 2 day survey process. NYSHFA was notified today that this pilot has started in a capital district facility. This is what we know thus far:

The team that is conducting the survey is a combined team, with NY surveyors from around the state, and a CMS representative.  There are six surveyors in all:

  • 2 from New Rochelle office,
  • 2 from Central office,
  • 1 from Syracuse office, and
  • 1 CMS-contracted surveyor (Dr. Alice Bonner PHD, RN from Northeastern University, who used to be the head of CMS surveillance services. Dr. Bonner has already participated in surveys in 4 other states as well.)
  • The team arrived with a letter from Jacqueline Pappalardi indicating that they were here to conduct an on-site focused survey regarding dementia care. That the survey is part of a CMS pilot program that is intended to document dementia care practices in facilities and associated care planning for nursing facility residents. The pilot was announced earlier this year by CMS in Survey & Certification (S&C) Memorandum 14-22-NH Focused Minimum Data Set (MDS) and Dementia Care Surveys.
  • Immediately upon Entrance the team is to be provided The Facility census number and a resident census for all residents with any diagnosis of dementia, room numbers and date of admission, List of Residents on leave, completed Roster, Bath/Shower Schedules, meal times, activity calendar and log of attendance, med pass times, care plan conferences that are scheduled, and a surveyor attended care conferences yesterday for all those with a dx of dementia.
  • The team asked for QA coordinator name, staffing schedules last two weeks calculated per patient day or hours.
  • The team also wanted all Policies and Procedures that related to dementia care and to staff training on dementia care.
  • The team did review closed charts of only those residents that were discharged having a dementia diagnosis, they all stayed until 6:30pm the first day and back the 2nd morning at 6:00 a.m.

DOH has selected the next 4 facilities already, so we anticipate they will assess the first survey process and begin moving to the next one. NYSHFA will keep you posted on any additional information.


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

Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15