January DOH/Provider Meeting Summary

Nancy Leveille and Lisa Volk in Clinical & Quality

The primary topics discussed this month are as follows:

  1. Current life safety issues
  2. Water sampling and management for legionella disease
  3. The New ROP
  4. Collaboration for 2017

See below for full information. We have contact information, website and attachments included in the summary related to these topics for access to resources. 

NYSDOH and Provider Meeting
Meeting Summary
January 12, 2017


The following topics were discussed at this month’s meeting:

1.  Life safety requirements: NYSHFA asked DOH for an update on current life safety issues they are focusing on related to the 2012 Life Safety code and current NFPA Regulations. DOH is focusing on the following new requirements during survey:

  • Maintenance and documentation of patient care equipment/personal items: DOH has developed a draft checklist for SNF providers to identify patient care equipment/personal items used in their SNF. At survey entrance, this checklist will be requested to be completed within 24 hours. (See attached Equipment Inventory Form). Surveyors will then review documentation of the SNF’s systematic plan to conduct evaluation of items for safety, maintenance (per manufacturer’s recommendation) and its current working order. In addition, they will review the actual documentation that notes the implementation of this plan per patient care item.
  • Revised FSES (Fire Safety Survey Report) forms:  DOH noted that there is a new revised FSES form for providers to use. It is CMS form 2786W910/2016). A copy can be found at:  https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html. The FSES is another way to evaluate your compliance to the 2012 life safety code.
  • Annual inspection of all Facility Doors:  There is a new DOH Dear Administrator Letter(DAL) that has been developed and will be distributed soon to provide guidance related to the new requirement of an annual inspection of all fire rated doors, smoke barriers and electronic locking doors by qualified personnel. This requirement includes the documentation of the annual inspection, any significant outcomes and the competency of the qualified person. Most facilities do this inspection already, but the new requirements necessitate review of the documentation of the inspection and its outcomes and the review of the qualifications of the person conducting the inspection by the state surveyor. DOH will provide more information once the DAL is distributed. SNF will have time to comply thereafter.

2. Requirements of Participation:  DOH discussed information that they have received from CMS’ webinar and a follow up call yesterday related to the three phases of the ROP. They are working off the CMS checklist and CMS’ original 3-hour webinar. NYSHFA has sent many of these materials out to members in the fall and provided specific training in November at NYSHFA’s Fall conference. CMS advised DOH they will be receiving an advanced copy the ROP Guidance most likely in May. They did note that the survey will change and be a combined standard and QIS survey process which is slated to begin next fall. The complaint process will remain the same. This new survey will have 70% of the sample resident group determined by offsite information from the MDS and 30% will be taken from onsite initial observations. 8 residents and 3 families will be interviewed each survey and the resident council versus just the council president will also be interviewed. Hospice notifications and dialysis programs will be a focus. Training on the new survey process will be conducted in the summer mostly by webinar format. NYSHFA questioned the reliability of the learner’s outcome by that method to ensure consistency of practice. DOH knows there are a lot of questions that will need to be explored and have set up a new email address to send questions to so that they can collect and analyze them and then provide education to the state providers. The email address is: NHROP@health.ny.gov.

Member note:  NYSHFA has developed a ROP work plan that is on our website at www.NYSHFA.org  on the front page under the ROP ICON for members. In addition, we have resources available for members on this webpage and will continue to update this page regularly.

3.  Legionella Water Testing:  Ernest Clement, MSN, RN Infection Preventist and David Dziewulski, PhD, Chief, Water Systems Control and Analysis, NYSDOH Bureau of Water Supply Protection presented information on Legionella disease and the water sampling and management process. (See LTCF LD Slides and Final HCF Memo.) NYSHFA discussed the need for more assistance to SNF providers to help ensure they are following the directives properly as they are not as clear as desired and want to ensure their compliance. The DOH staff acknowledged this and have actually developed some additional guidance that will be forth coming. We requested the ability to have them provide some education with the new guidance and they were open to this and also assisting SNF provider via email, phone as well. Questions for water sampling can be sent to HCF.legoionella@health.ny.gov or David.dziewulski@health.ny.gov or by phone at:  (518)-402-7650. For clinical information email at ICP@health.ny.gov or call Ernest Clement at (518)474-1142.

DOH provided a list of state approved water sampling labs. See attached list.

4.  Collaborative Projects 2017:  DOH wants to discuss work on the following topics (or other suggestions) to improve care in SNF during 2017. They are exploring how to utilize the Civil Money Penalty (CMP) dollars to assist these efforts with a statewide effect. Topics under consideration include:

  1. Continuing to reduce the QM on Facility Acquired Pressure Ulcers
  2. Continuing to reduce the use of Psychoactive medication and move from a rate of 13% to 10% in NYS
  3. Infection Control and Antibiotic Stewardship
  4. ROP
  5. QAPI

Please contact Nancy Leveille or Lisa Volk for any questions/comments from this summary or suggested agenda items for next meeting.


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

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15