DOH/Nursing Home Provider Meeting Summary - October 2019

Lisa Volk and Jackie Pappalardi in Clinical & Quality

On Thursday, October 17, 2019, NYSHFA staff met with DOH and following key points were shared:

CHRC Update

DOH Legal and Program staff shared a DAL which will be issued soon on CHRC update.

Facilities should contact CHRC with any mistakes noted with a submission. Do not send in another CHRC form. Call CHRC directly with questions or changes related to finger printing:

Pre employment finger print -  or call 518-402-5549

Post-employment determination follow-up should be directed to Legal: or call 518-408-1627

Facilities should not send prospective employee personal identifier’s unless specifically requested. Any requested information should ONLY be sent using the contact button through a secure line.

CHRC is proposing a regulation change for clarification of the requirements for employee fingerprint completion date to 21-days. Compliance to this requirement will be reviewed during survey.

Providers are required to update the HCS role directory as employee positions change including removal of employees no longer employed by the facility.  There should be a minimum of two employees assigned the Authorized Persons (AP) role.  The expectation is for the AP to monitor updates 7 days a week. Supervision is required until the final CHRC determination is received to ensure protection of the resident. Do not use old hard copies for forms 103 & 105.  Only use electronic 103 & 105 forms.

Licensed Nursing Home Administrator (NHA) Renewal

NYS has a database of 1400 active & non active NHA. To date, only 33% of the renewals have been received: 328 (50%) of the AOR and 142 (17 %) of the non-AOR. The registration period ends on December 31, 2019. Administrators of Record who do not renew on time will be referred to BENHA which could result in a fine (up to $1000.00) and a legal mark against their NHA license. BENHA plans to go electronic via e-portal for the next registration period. DOH is accepting nominations for the two open seats on the BENHA Board - 1 Public and 1 NHA for profit.

DOH Discussion of Recently Released DALS:

August 20, 2019 Notice of Transfer or Discharge - DAL-NH 19-07. Requirements for residents discharged and/or transferred to an acute setting including the requirement for proper notifications. DOH has a template available upon request. Ombudsman contact information and a set of frequently asked questions are included. No update on the expected date of release of the Bed Hold frequently asked questions document.

September 5, 2019 Mandatory Weekly Bed Census - DAL NH 19-08.  The weekly bed census is now a mandatory function. Facilities will be cited for not completing. New categories capture onsite home hemodialysis units at the bedside and in dens; neurodegenerative beds and total pediatric vent capacity. Includes a FAQ section.

September 25, 2019 Dialysis - DAL NH19-09. Regulatory requirements reviewed for home dialysis in nursing homes. Currently 13 facilities have completed the licensure process.

October 7, 2019 IDR Process-Discussion of DAL NH 19-11. Providers must submit the IDR in a word format and are encouraged to save the IDR form from the DAL for future reference.

DOH announced soon to be released DALs:

Advance Directives

Resident Rights - Share discharge information on admission and document in Section Q of the MDS. New requirements mandates posting the contact information for the local agency for discharge information in a visible area for residents and families to see.  Surveyors will check posters are in place by mid-November. The New York Association on Independent Living (NYAIL) Open Doors Transition Center handles requests for information and support for residents/families seeking discharge information.

The Regional contact information for the Open Doors program can be found at  Their toll-free number is 844-545-7108. 

Environmental Cleaning - DOH will be requiring all environmental service staff watch a video on infection control and cleaning techniques. The video is in English and Spanish.  All training records should be retained. Surveyors will be looking at compliance. HERDS survey will be issued soon.

2-hour Rule related to Abuse - NYSHFA advocated for clarification due to provider confusion when reporting an alleged abuse as a reportable incident and where to document when the incident was determined not abuse. DOH plans to issue clarification guidance and will consider removing the manual until the update is complete. CMS is looking into a system of triaging abuse and neglect and changes in ASPEN and ACTS survey systems.

DOH Announcements

CMP Projects - A RFP will be released in the first quarter of 2020 for the use of CMP dollars. The expected topics will be workforce development and behavior health programs. NYSHFA has been a strong advocate to both CMS and DOH to release CMP funding for the development of quality improvement programs including the recruitment and retention of healthcare workforce and expansion of trauma informed care and related behavior health programs in NYS.

Status on the Rules of Participation (ROP) Phase III Proposed Hold - No CMS guidelines have been released to states following the end of the comment period in September. Providers are encouraged to implement Phase III requirements per the November 28th final date.

CDC Enhanced Barrier Precautions Guideline Released. See attached. DOH Epidemiology reviewing guidelines. DOH expectation is to follow best practices as defined in the State Operations Manual (SOM).

Surveys forward to CMS - DOH forwards all SODs with citations for Abuse F-600 series, Discharges and Antipsychotic Late Adopters to CMS.

DOH Pre Survey Review - DOH staff does not look at the % star ratings prior to survey.


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

Jackie Pappalardi, RN, BSN
Director, Educational Development & Grant Mgmt.
518-462-4800 x16