DOH/Providers’ April 2019 Meeting Summary

Nancy Leveille and Lisa Volk in Clinical & Quality

On Thursday April 18, 2019 NYSHFA staff met with the DOH and the following key points were discussed:

1.   CMS Guidance regarding Immediate Jeopardy and DOH’s Implementation

DOH discussed the expanded CMS direction to increase consistency with appendix Q and identifying, citing and communicating Immediate Jeopardy (IJ).

  • Key Components of Immediate Jeopardy – To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.
  • Immediate Jeopardy Template – A template has been developed to assist surveyors in documenting the information necessary to establish each of the key components of immediate jeopardy. Survey teams must use the immediate jeopardy template attached to Appendix Q to document evidence of each component of immediate jeopardy and use the template to convey information to the surveyed entity.

Points to highlight for providers are that Likelihood, is a higher level to achieve than Potential has been in the past to cite an IJ. Likelihood is defined to mean that there is a good chance this situation will occur again vs a general potential that it could.

They also noted that the facility must be in Non-Compliance for the IJ to now be cited. Culpability has been removed.

Psychological harm:  has been further defined to include when the cited noncompliance has caused or made likely serious mental or psychosocial harm to recipients. In situations where the psychosocial outcome to the recipient may be difficult to determine or incongruent with what would be expected, the guidance instructs surveyors to use the reasonable person concept to make that determination. The reasonable person approach considers how a reasonable person in the recipient’s position would be impacted by the noncompliance (i.e. consider if a reasonable person in a similar situation could be expected to experience a serious psychosocial adverse outcome as a result of the same non-compliance.

IJ Template:  CMS has established a notification process for surveyors to follow when immediate jeopardy is identified which DOH will begin to use. This process ensures that providers, suppliers, or laboratories are notified as soon as possible of an immediate jeopardy finding. This process is intended to increase transparency, and improve timeliness and clarity of communication to providers, suppliers, and laboratories. The new IJ template has three components, Non-compliance, serious injury, serious harm impairment or death and need for immediate action. This template will be time and date sensitive. DOH reminds providers that the quicker the IJ is identified the quicker it will be removed, additionally that the removal plan deals with the immediacy of the issue and the POC corrects the deficiency.

No automatic immediate jeopardy citations:  Core Appendix Q makes it clear that each immediate jeopardy citation must be decided independently and there are no automatic immediate jeopardy citations. Therefore, each Statement of Deficiency must be able to stand on its own merit. And IJs need to be communicated to the provider as soon the DOH surveyor identifies that there is one. The DOH surveyor cannot leave the SNF until the immediacy of the IJ has been removed and the plan to correct is in place.

The complete CMS memo QSO-19-09 can be found at:

and NYSHFA’s previous member mailing on this topic can be found at:

2.   Enhanced Oversight and Enforcement – Antipsychotic Medication Reduction Late Adopters

Currently NYS is listed at 11.3 % for antipsychotic medication utilization for long-stay nursing home residents. NYS is ranked at #5 in the country continues to be a leader nationally. Currently, there a total of 35 Late adopters in NYS. DOH is working with each of these SNF. CMS set a goal for a decrease of antipsychotic medication use by 15 percent for long-stay residents by the end of 2019. NYSHFA is encouraging providers to continue to evaluate their antipsychotic medication utilization facility rates for long-stay nursing home residents and to implement appropriate GDR as needed.

CMS outlined their plan for enhanced enforcement  via QSO -19- 07 NH memo

NYSHFA’s  March Member Mailing has some additional information from AHCA:

3.   Schizophrenia Surveys: DOH noted that they had data demonstrating an uptick of cases of Schizophrenia diagnoses occurring in SNF across the state. Therefore, they conducted a total of seven focused surveys on this topic. They found some discrepancies in the medical records that warranted the issuance of lower level deficiencies.

4.   Safety Hazards - DOH reports recently there has been 5 incidents of resident to resident assaults reported in the last few months. The residents used medical equipment as weapons in a few cases.  They are asking that equipment that is keep in the resident’s room or in a public area that could be used a weapon be removed i.e. (wheelchair legs, B/P cuffs etc.) DOH wants to remind providers that the police must be notified and that a police report filed. If the police do not take a report or issue a report then the facility should go to a higher supervisory level within the police department.

5.   Update on open complaints and survey timeframes- DOH reported that they are trying to reduce the timeframe for closure of complaint cases. Closed case notifications are being are being sent out via email.  DOH notes that some of the email addresses may not have been updated when the LNHA or DON turns over. NYSHFA recommends the facility’s role directory be updated with the current administrator and DON so the notices can be received. Improvements continue to be made on the 15-month time frame.

DOH also reports that their plan is for all SNF to receive at least one of the new standard survey processes by the end of June. Delays sometimes occurred due to an Immediate Jeopardy situation in the state. DOH recognizes the addition of looking at all residents, as well as review of both Legionella Water Management Plan and Emergency Preparedness program has added to the number of survey days. Currently the average length of survey is at 5 days. DOH also encourages providers to complete their Quality Improvement survey at the end of the survey process. DOH reminds providers that 10 % of surveys will continue to happen on off hours including holidays. Complaint surveys are also being conducted during those off -hour timeframes.

6.   Bed Census:  a new DAL will be issued soon; the bed census will continue to be submitted weekly and will include any units with enhanced rates.

7.   ADHC Programs:  a DAL and Self-Assessment will be released soon under the HCBS rule. A webinar will be given prior to completion of the form. DOH is encouraging ADHC programs to be honest as possible so they may assist programs with additional training requirements and compliance.

8.   Medication Technicians:  NYSHFA continues to advocate for the need for the work group to discuss this topic further. This topic is being discussed in a DOH Quality/Workforce subcommittee.

If you have questions or comments or want to add agenda items to the next meeting, please contact Lisa or Nancy.


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