DOH/Nursing Home Provider Meeting Summary - January 16, 2020

Jackie Pappalardi and Lisa Volk in Clinical & Quality

On Thursday, January 16, 2020 NYSHFA staff met with DOH and following key points were shared: 

Livanta-Memorandum of Agreement (MOA) of Compliance and Medicare Patients Notices

Representatives from Livanta discussed the MOA requirement for facilities that receive Medicare funds for Medicare services. Livanta is assigned as the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to assist CMS in the roll out of the 12th Scope of Work of the Quality Improvement Organizations. BFCC-QIOs are responsible for medical case review to support the rights of people on Medicare. At this time, Livanta has collected 25% of the MOA’s from facilities. The CMS goal is 95%. Please complete the MOA utilizing the link below. You will need to have Adobe Reader to open the MOA documents:

CMS - New Beneficiary Notice for SNF’s is now available on the BNI website link below:

Both Medicare beneficiaries and providers have certain rights and protections related to financial liability and appeals under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.

Updates from the Bureau of Narcotics Enforcement (BNE) on narcotic drug destruction onsite

The guidance from BNE for the destruction of narcotics is under final review prior to release. The items covered in the guidance include collection receptacles, liners, security, which scheduled narcotics can be placed in the receptacle, forms to be used as well as the pharmacy and facility’s responsibility. NYSHFA advocated for an approved list of vendors for the collection receptacle.

CNA Training Online

DOH has checked with other states as well as Prometric and SED, no other states are conducting this training online at this time.

Emergency Kits / Automatic Dispensing Machines (ADM)

DOH agrees the Emergency kits and ADM’s are beneficial to the Nursing Homes for timeliness of medications, tracking and cost containment. NYSHFA will continue working with DOH and SED on required legislative changes needed. Recent survey issue related to the ADM use in nursing homes has been addressed.

Advance Training Initiative – Office of Health Insurance Program (OHIP) gave no updates on timeframe changes. Of note, OHIP obtains data from the cost report. Facility representatives attending programs offered by NYSHFA have been advised to send OHIP a letter requesting an extension to December 30, 2020 to complete training at their respective facilities.

CMS: Requirements of Participation - No new updates received. Expectation is for compliance with Phase 3 requirements. CMS regional office staff responsibilities are under restructure.

Update on Civil Monetary Penalty Proposal for Requests for Applications

DOH is proposing to release information for two non-competitive grants in the amount of $500,000 each. The grant funding would be awarded directly to the facility to assist with resident Quality of Life and Quality of Care projects. DOH expects the release will be in three months.

Annual Coastal Planning

NYSDOH Commissioner released a DAL on 12/20/19 outlining the 2020 Coastal Storm & Flood planning activities required for facilities located in NYC. This document is intended to support facilities in collecting key facility-based data needed for completing all required components of the HCS, HERDS Critical Asset Survey (CAS) and the Facility Evacuation Planning Application (FEPA) for successful emergency response. The compliance period is January 1, 2020 through March 31, 2020. Providers are encouraged to check their facility send and receiving agreements. NYSHFA encourages providers that do not have these agreements to reach out to those regions outside of the zone to develop agreements with area facilities. OHEP staff will be available to offer technical assistance through the compliance period and can be reached at 518-474-2893.


DOH noted that nursing home practice for Advance Directives continues as an ongoing problem for staff response. Providers are reminded to review their systems, policies and responses and educate staff on the policies on a regular basis.

Clarification of Two-Hour Rule

Providers must report immediately, but not later than 2 hours, all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property. The DOH is working on a triage system internally, a DAL letter will be forthcoming. The DOH reminded facilities that it is their obligation to notify the police. DOH is tracking the data associated with notification and have noted an increase in reporting. All alleged abuse allegations are referred to the AGO. 

Evacuation of Western NY Facility

DOH provided an update on the December 2019 evacuation of a Western NY facility due to two separate incidents involving flooding situations. DOH participated in the emergency operations center opened in Buffalo and held frequent calls with the facility. DOH reported the facility worked well with DOH and utilized the regional plan with community partners. The facility successfully evacuated all their residents without any major problems. The second evacuation occurred on December 24, 2019. An After Action Report (AAR) will be completed.

Next meeting is scheduled for Thursday, April 16, 2020.


Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16

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