DOH- Provider Minutes 7/18/19 – Important Notice to our Reporting Rule

Jackie Pappalardi and Nancy Leveille Lisa Volk in Clinical & Quality

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


Two Hour Reporting Rule: Alleged Abuse and /or Bodily Injury

After receiving questions from several members regarding the time rule for reporting allegations of abuse, NYSHFA requested DOH to explain their position: DOH clarified that with the New CMS RoP, SNF must report allegations of suspected abuse and /or serious bodily injury to a resident to the administrator and NYSDOH within 2 hours based on Federal code 483.12(c)(1).

DOH has been citing facilities under F609/610 Reporting Alleged Violations/Investigation for lack of reporting within the required 2-hour rule for suspected abuse. We have only seen lower level deficiencies on this thus far but could lead to higher level deficiencies if not reported according to the change in regulation.

NYSHFA believes this new Regulation has been developed based on Section 1150B of the Affordable Care Act which requires that LTC facilities must report to the state agency and at least one local law enforcement entity any reasonable suspicion of a crime, as defined by local law, committed against an individual who is a resident of, or is receiving care from the facility.

DOH shared this highlight from Section 483.12(c) (1) of the State Operations Manual:

“In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.”

The NYSDOH Incident Reporting Manual (2016) has not been updated to include the 2-hour rule requirements. DOH reported there is work underway to align the federal 2-hour reporting requirements with the current state requirements.

NYSHFA stresses to our members the importance of communicating the 2-hour reporting change to all your facility staff including the staff working off shifts and on weekends. Staff should be knowledgeable on utilizing the Incident Reporting System on the Health Commerce System (HCS) to report an incident of suspected abuse within 2 hours as required. In the event HCS is not functioning, it remains the responsibility of the facility staff to notify NYSDOH using the Hotline.

We encourage you to report as indicated and then continue your full investigation into the situation. NYSHFA staff are meeting with CMS Region II staff in a couple weeks and have this issue on the agenda to discuss. We will keep you updated with any new information as it becomes available. 

Other Key Topics:

Patient Driven Payment Model (PDPM)

DOH introduced the newly appointed RAI/MDS Coordinator. DOH provided a brief update on PDPM as it relates to resident care and surveillance.

DOH shared they will continue to conduct surveillance on current areas surveyors assess for compliance under Resident Assessment (483.20): F 636 Comprehensive Assessments and Timing; F367 Comprehensive Assessment After Significant Change; F 641 Accuracy of Assessments and F 642 Coordination and Certification od Assessments. DOH noted the significance of strategic planning for staff scheduling to remain compliant with schedule changes. DOH shared a document listing PDPM Resources for references.

DOH shared the current requirements under Admission, Transfer and Discharge (483.15):

Bed Hold (F 625)

There will be an updated DAL and FAQ released regarding Bed Hold. Under F 625, the nursing home is required to allow the resident to return from the hospital to the next available semi-private bed. DOH noted that all beds are dually certified even if located on the rehab unit and all returning residents take precedence for bed placement over a new admission. NYSHFA has been sending the DOH a list of members questions. If you have any others, please email them to Carl Pucci at

Permitting Residents to Return to Facility (F 626)

DOH stressed the importance of nursing homes reading the regulations for transferring a resident to a hospital. This is a transfer not a discharge. The hospital is not a discharge location.

Update on Med Tech

NYSHFA asked for an update on the status of the formation of this workgroup. DOH shared that Mark Kissinger, Special Assistant to the Commissioner of Health, has responsibility for heading this group. DOH will be meeting with SED to discuss modeling a med tech position similar to the OPWDD model currently in practice. Based on NYSHFA’s discussion with SED, this may require a legislative amendment to the NYS Nurse Practice Act.

Styrofoam Ban NYC

Survey and Surveillance will not be citing this and did not have any guidance regarding this and will be referred to the local law regarding this. 

Updated LTCSP - DOH is reviewing the data on a quarterly basis. Here are the top five deficiencies for both National & NYS:

National Top Deficiencies

1)   Infection Control

2)   Accidents/Supervision

3)   Food Procurement

4)   Care Planning

5)   Quality of Care

NYS Top Deficiencies

1)   Care Planning

2)   Infection Control

3)   Unnecessary Meds

4)   Food procurement

5)   Investigations

Average number of deficiencies
National 6.7   NYS 5.2 

Number of Deficiency Free Surveys
National 7.2   NYS 7.6 

Number of Investigations Surveyors Completed / The % that Lead to Citations
National 52 - The % that lead to citations 15.7     NYS 52 - The % that lead to citations 15.4 

Survey Updates

  • DOH is working on lowering the time onsite during survey which has been delayed due to the number of new surveyors; the surveyor training curve and the yearlong shutdown of training by CMS that lead to delays getting new employees trained.
  • Survey times remain outside of the 15.9-month window.
  • DOH recently employed new surveyor staff and has received an additional hiring package.
  • DOH is looking at the practice of conducting surveys for the lower performing facilities within the 15-month time while looking to delay the surveys for higher performing facilities, based on risk.
  • DOH continues to review all regions for survey disparities utilizing their QA process including reviewing the survey tool kit for consistencies between all regions.

IDR Review

DOH reviewed the process for submitting the request for an IDR: within 10 days, the provider completes the IDR form found on the HCS (under NH-Forms). Deficiencies cited at B-F excluding SQC are sent to the Regional Office citing the deficiency for an Administrative IDR review to determine if it will be upheld, changed or expunged. The surveyor that cited the deficiency will not be the one to review the IDR. Direct questions to Tarrah Quinlan or Helen Hines at 518-408-1267. A DAL will be coming out soon.

Questions posed to DOH for information on the following topics:

1)   Hazardous Waste Pharmaceutical Rule promulgated by the EPA. The new rule revises management standards for the management of hazardous waste pharmaceuticals (HWP) for health care facilities and reverse distributors. These provisions prohibit the disposal of HWP down the drain (sewering). The ban on sewering HWP will go into effect nationwide on August 21, 2019. DOH reported they are working with the Division of Legal Affairs (DLA) and the Bureau of Narcotic Enforcement (BNE). More information to come.

2)   Delay of some RoP Phase III requirements. Announcements by CMS on the delay of some of the Phase III requirements of the Rules of Participation for an additional 12 months beyond the expected date of November 28, 2019. DOH will review CMS ruling and provide information at a later date. Information on the delay of implementation will be communicated to the surveyor staff through scheduled DOH meetings with regional office program directors.

3)   Availability of PPD. NYSHFA asked DOH about the PPD shortage. DOH felt this shortage would be short term and did not feel any special guidance is needed at this time. If there are shortages that are impacting the facilities, please reach out and let NYSHFA know so we can convey this to the DOH.

4)   Post Survey Provider Evaluations-Feedback to DOH. DOH stressed the importance of provider’s returning the evaluations after each survey. The recommendation was to be specific in sharing your concerns. The comments and feedback are taken very seriously. 

Next DOH Provider Meeting is October 17, 2019.

If you have issues you want NYSHFA to address please contact Lisa, Jackie or Nancy.


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

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

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