DOH/Provider Meeting Summary – November 2018

Nancy Leveille and Lisa Volk in Clinical & Quality

On Thursday, November 29, 2018, NYSHFA staff met with DOH and the following are key points discussed: 

1. DOH Staff Changes Announced:  Shelly Glock reported that she is being promoted to the position of Deputy Director, Center for Health Care Planning, Licensure and Finance, and that Sheila McGarvey is being promoted from Deputy Director to the Director, Division of Nursing Homes and ICF/IID Surveillance, Center for Health Care Provider Services and Oversight. Effective date targeted for January 1, 2019. They are currently recruiting for Sheila’s replacement, but all other key positions are currently filled.

2. Advanced Directives Clarification:  NYSHFA has advocated for clarity for members related to what is acceptable to identify residents who request to be DNR or have CPR initiated when a resident becomes unresponsive. DOH referred the providers to their latest DAL dated January 4, 2007. They also referred the CMS regulations and guidance. The basics of this guidance notes the following:

  • SNF must have in place systems, policies and procedures that ensure that the resident advance directives regarding basic life support will be identified, known and honored.
  • They noted that there should be one main source document that is readily available 24/7 which easily identifies their wishes and that all staff know where that document is held.
  • With regards to EHR and kiosks, the source document can be stored there, but must be accessible 24/7 and able to be retrieved immediately upon an emergency. Back up printed source documents may be needed as a backup to electronic power failure.
  • Procedures for how to call and respond to a resident emergency of potential or actual cardio/respiratory arrest need to be in place and tested.
  • These type of emergency codes need to be drilled on scheduled timeframe to test the system and competencies of staff on the procedure and techniques used in an emergency. Lessons learned from the drills should be used for quality improvement solutions. i.e., education, revisions of procedures, enhancements to process, etc.
  • DOH will not prescribe the SNF system or procedures but will assess how well it works to ensure the advanced directives are followed.
  • DOH noted they find failures related to:
    • Too many places the advanced directives are kept and therefore not updated as changes occur causing confusion.
    • They noted failures with the wristband dot system and resident care cards in the closets as not being updated or moved as residents changed rooms or were discharged. These are not federal requirements.
    • DOH encourages a simple system that is tested and works.
    • Staff did not know how to call a code from any area in the facility.
    • Staff did not always have a system in place to note whose role it is to call the code, who should respond to the code, who pulls the source document to determine immediate action needed, who should bring what equipment to the potential code site and who is in charge of running the emergency.
    • Not drilling on the SNF system covering all shifts and weekends to discover strengths and weaknesses in the system.
  • These issues have been the Basis for IJs being cited related to Advanced Directive.

3. Civil Money Penalties (CMP) and Life Safety (LS) Issues:  The group discussed changes from CMS that now cite LS issues at the IJ level. CMS is now citing some of the LS issues if they relate quality of resident care. DOH is assessing each of these potential higher-level deficiencies. NYS has not had a lot of these cited thus far. However, they have identified that some changes related to deleting points for sprinkler systems on the FSES forms have negatively affected the rating system. Now SNF FSES rating may not meet the safety level. The Nation Fire Protection group identified this as an unintended consequence to taking points out of the rating system once all SNF across the country were required to install sprinkler systems (thus causing those that have been deemed safe via the FSES system to now appear unsafe). They plan to correct this with the next set of rules in a couple years. In the meantime, most states have 3-year waiver process in place to assist with the FSES issues. NYS only has a 2-year waiver process which is making SNF correct LS issues that have been accepted as safe based on their previous FSES pass rate. The cost they may incur range from $100,000 to millions. NYSHFA requested previously and again to reassess our NYS waiver process to allow for 3 years for these types of issues.

4. New Survey Process:  Year one of the new survey has just been completed. Survey staff are still being trained and many need to pass the federal survey competency. Since many surveyors retired this year, DOH has hired new surveyors to complete their teams in all regions and have been actively getting them on board. By 2019, DOH feels they will be back on schedule with the 9-15-month survey windows. DOH provided the top survey issues for the year. Attached is the report they provided at our fall conference. IJ and G level deficiencies have decreased this year. The top IJ are in accidents with injury/hospitalizations; advanced directives; respiratory care with ventilators/trach care and infection control.
5. CMS Initiatives:  DOH reported that CMS has a couple new initiatives:
  1. Life safety workgroup - now the surveillance staff can participate in to discuss issues that come up in survey as mentioned above.
  2. LTC survey data reports and analysis that will provide better data for DOH to assess trends; comparison data etc. in a timely fashion.
  3. CMS is developing new guidance for handling facility reported incidents. CMS acknowledged NYS’ system as a model.
  4. CMS is planning for a Casper system upgrade.
  5. CMS is developing guidance on involuntary resident discharges.
  6. 5-Star to be revised in Fall 2019.

For questions/comments or to add agenda items to January’s meeting, please contact Nancy Leveille or Lisa Volk.


Nancy Leveille, RN, MS
Executive Director
518-462-4800 x20 

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