DOH/Provider Meeting Summary – January 2019

Lisa Volk and Nancy Leveille in Clinical & Quality

On Thursday, January 17, 2019, NYSHFA staff met with DOH and the following are key points discussed:

Sheila McGarvey has been named the new Division Director of Nursing Homes & ICF/IID Surveillance Center for Health Care Provider Services and Oversight. Ms. McGarvey served as the Deputy Director Division of Nursing Homes and ICF/IID Surveillance Center for Health Care Provider Services and Oversight prior to assuming the role.

A.      CMS Initiatives:

Federal Oversight Support Survey (FOSS)

Originally, the key areas that were looked at on the FOSS survey were abuse, dementia, admission, transfers and discharges. The following will be added in the 2019 Infection Control: accidents, supervision, pressure ulcers new or worse.

S & C Memos

Survey & Certification memos are now called Quality Safety & Oversight memos.

CMS & DOH – Staffing Levels

CMS & DOH will focus on staffing levels based on PBJ data analysis. CMS will begin informing state survey agencies of facilities with potential staffing issues; facilities with significantly low nurse staffing levels on weekends; and facilities with several days in a quarter without an RN onsite.

Facilities identified as having low staffing on weekends: The State Operations Manual, Chapter 7, Section 7207.2.2, requires states to conduct at least 10 percent of the standard health surveys on the weekend or before 8:00 a.m. or after 6:00 p.m. (i.e., “off-hours”). DOH noted they are conducting more than 10 % of these surveys based on complaints.  At least fifty percent of the required off-hours surveys will be conducted on weekends using the list of facilities provided by CMS.

Facilities identified as having reported days with no RN onsite: CMS is aiding surveyors’ investigations by identifying facilities who have higher risk of noncompliance with the RN staffing requirement. When conducting a scheduled standard or complaint survey (regardless of the type of complaint), surveyors will be investigating compliance with 42 CFR 483. 35(b)(1), which is the requirement for a facility to provide the services of an RN seven days a week, eight hours a day. If a surveyor confirms that this requirement has not been met, the facility shall be cited for noncompliance under deficiency F-tag 727. 

5 Star Survey Data Freeze Update

CMS is targeting the release of data in the spring, as well as the release of citation rates for all states in October of 2019.

Nurse Aide Training Bans

DOH remains in discussion with CMS regarding Nurse Aide training bans and fines associated with unintended consequences.

CMS Infection Prevention Training

No further updates regarding release of this training. 

B.      CHRC Increase in Fee/Delays:

The CHRC department is now under Justice versus DOH. The CHRC fee has recently increased from $99 to over $100. Lead Staff is transitioning from Cody Pines to Jillana Devik. NYSHFA reinforced the need for timely checks due to the need to get staff to work and the need for sites in rural areas or testing sites at nursing homes if needed. Mr. Pines discussed that four new facility types have been added to the CHRC system, therefore, slowing the processing. More CHRC employees are being hired and a new internal database has been added. NYSHFA asked for a list of the fingerprinting facilities across the state (see attached.) To help with decreasing the errors to speed up processing NYS DOH advised to follow these steps:

  • Check the employee ID for errors.
  • Include the last 4 numbers of the Social. This is not required but helps with processing.
  • Instead of faxing, it would be better to scan documents as it is easier to read. It can also be sent via an attachment on the CHRC document. See contact information below for further questions:

NYS Western Region Legislator Making Recommendations for Potential Change to Off Hour Surveys

NYSHFA discussed Senator Ortt of Towanda announcement that he is proposing a package of bills to protect nursing home residents and improve the care they receive in facilities across the state. Recommendations include increase surveys on off hours. DOH maintains they will continue to follow the federally prescribed CMS survey schedule with 10% of surveys being conducted during off hours.

C.      Medication Technicians:

NYSHFA asked about the progress of evaluating this topic. A work group will be initiated to get all the stakeholders involved to discuss the matter of medication assistants. Mark Kissinger, NYS DOH, will be heading the group. 

Delays in Investigation of Self-Reported Incidents

Fiscal Year 2018 DOH reported they reviewed 8,500 complaints and incidents; of these approximately 11% resulted in citations. The DOH staff review each of these for any imminent danger and has a triage system of how they are handled.

  • Actions include: no action, 2-day, 10-day, 45-day or review at annual survey.
  • These complaints and incidents continue to be reviewed based on the information that comes into the DOH office.
  • These time periods regarding the DOH follow-up may get pushed back if an increase number or higher level of complaints come in.
  • If there is a lag time between when an incident was reported and when the DOH comes in, it may result in a deficiency.
  • If the issues have already been corrected, then the SOD would state past noncompliance. 

Transfers, Admissions and Discharges

Deficiencies associated with transfer, admission or discharge will be forwarded to CMS for review. Remember, all beds in the SNF’s are certified for Medicaid and Medicare, no such thing as subacute. Admission agreements should be looked at for the appropriate wording, subacute does not hold up, subacute is not to be used. The NYS DOH Complaint Department, discussed the following items:

  • Refusal to accept a resident with behaviors back into the facility when the hospital records indicated behaviors and that a diagnosis is present on admission. If a facility is agreeing to take a resident with behaviors, then they must be able to care for them. The hospital is not a discharge outlet.
  • Failure to provide a comprehensive discharge care plan, such as services not being set up prior to discharge.
  • Lack of notification required of resident and resident representative regarding discharge
  • Lack of notification to the Ombudsman of Involuntary discharge.
  • Section Q of the MDS not being correctly completed: Q400, Q500 and Q600. It’s important that the return to community questions are asked so that discharge planning can occur. Remember that to be considered an active discharge, the plan must be written, and the facility must have a tentative discharge date. If the resident says yes to the opportunity to going home, a referral must be made to Money Follows the Person (MFP). If further training is needed on this section regarding referrals to MFP, see contacts below:
    • Andrea Juris, MFP Project Director; Stacey Agnello, Program Advisor; Karen Smith, Associate Health Planner
    • Division of Long-Term Care New York State Department of Health  518-486-6562.

NYSHFA discussed C. Auris, and the key areas to look to prevent the spread of infection 

  • Hand Hygiene
  • Terminal Cleaning
  • Appropriate donning and doffing of the PPE 

See CDC guidelines 

Medical Marijuana 

There are a few facilities that have implemented the medical marijuana; DOH cited no issues under the Compassionate Care Act. The facility must follow the guidelines as far as the designated caregiver, storage, prescriber etc. A reminder that on a federal level medical marijuana is still illegal.


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

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