Issue: April 17, 2018

Published on April 17, 2018

Articles in this issue:

DOH Provider Meeting Summary - April

Author: Lisa Volk* Published in Clinical & Quality

On Thursday, April 12, NYSHFA staff met with DOH and the following are key points discussed: 

Money Follow the Person (MFP) Update:

MFP shared data related to MDS section Q and the education they have been conducting related to active discharge. Nursing home staff must ask Q0500 whenever the MDS is administered unless a resident has an "active discharge plan". 

MFP continue education in health care facilities over a two-year period and they hope to reach 300 facilities in NYS. NYSHFA did inquire the average time that they go into the facility once the referral is made. MFP states they have increased the staff in the city region to become more timely with seeing the resident after the referral is made.

Here are the excerpts from the DAL 16-10 MDS Section Q:

MDS Section Q, question Q0500 is designed to ensure that all individuals have the opportunity to learn about home and community-based services and receive services in the most integrated setting. If a nursing home resident answers "yes" to question Q0500, the nursing home must make a referral to the designated Local Contact Agency within a reasonable amount of time (the Resident Assessment Instrument [RAI] specifies a timeframe of ten business days). In New York State, the New York Association on Independent Living's (NYAIL) Open Doors program is the designated Local Contact Agency for all Section Q referrals.

Nursing home staff must ask Q0500 whenever the MDS is administered unless a resident has an "active discharge plan", meaning, as recommended in the guidance, that the resident has been referred to, and has met with, the Local Contact Agency to create a transition plan. Furthermore, facilities may not deny residents a referral to the Local Contact Agency for inappropriate reasons, including a belief that the resident's disability or care needs are too severe to transition or the resident's family or caregiver does not want the resident to move. In other words, the nursing home must make a referral to NYAIL/Open Doors whenever a resident answers "yes" to Q0500, regardless of whether or not staff believe a resident has the potential to return to the community.

Upon receipt of a referral, NYAIL will assign a Transition Specialist who will meet with the resident to provide objective information about available home and community-based options. If the resident wishes to transition back to the community, the Transition Specialist will work with the resident and all relevant support persons, including nursing home discharge staff and care managers, to offer peer support and provide community preparedness education and transition assistance. This assistance includes helping participants identify and access needed supports, benefits, and services in their local community. It is the expectation of the Office of Civil Rights and the New York State Department of Health that the nursing home staff tasked with discharge planning will fully cooperate with the Transition Specialist in order to assist the individual in returning to his or her community of choice.

When contacting the Local Contact Agency, NYAIL, please specify that the referral involves the MDS Section Q. NYAIL can be reached at 1-844-545-7108 or Should you have any questions, please send an e-mail to

See full power point presentation here.

Short Term vs Long Term Stays:

DOH has noted an uptick in the number discharge appeals over the last 3 months. Some of these were related to cases where the resident was there for short term rehab and then needed long term placement but needed to find placement elsewhere as indicated on the admission agreement.   

Admission agreement should not be designated for short-term stay only. CMS has asked to review involuntary discharges cases. NYSHFA recommends you review your admission agreements, additionally a reminder the NYS beds are dually certified.     

Costal Storm Preparedness:

DOH sent out a DAL in January to the facilities located in the NYC for completion of requires items to prepare for the coastal storms. The due date for completion was March 31st, 2018, not all facilities within those areas completed the required paperwork. DOH continues to work with providers to help prepare for the Costal storms    

Costal storm season begins, August 1, st. Currently 66 facilities in NYC are considered in an evacuation zones, 102 are out of the zone but in the area. A total of 21 providers have not completed the required work which was due on March 31, 18 for costal storms preparedness. A letter will be sent to the facilities who have not complied. The letter will address the next steps they need to complete. Of the 21 facilities many have the required tasks completed but may have one or two outstanding items. There are 11,000 residents in that area and 7,000 residents are covered by an active agreement receiving or sending facility. NYSHFA is encouraging providers to continue work on these plans. 

Legionella Update:

An increase in the number of citations have been noted under Infection Control related to legionella.

DOH will pass along checklist used and will recirculate the DAL related to Legionella. DOH states they have sent communication to facilities who have concerns in these areas with lack of responsiveness, next steps to come. NYSHFA is asking you to review your documents for your Legionella sampling plan. See attached DOH Memo and PowerPoint

HHS/OIG Life Safety/ Emergency preparedness Audit Update:

OIG is currently conducting a total of 30 facility survey’s related Fire Safety and Emergency Preparedness. Geographically, these surveys are dispersed across the state.

OIG pulled their own sample of facilities and is half way through these surveys. Here are some of the areas CMS is looking at Emergency Prep - training, polices, communication plan. Fire Safety - Egress, Exit doors and signs, alarms and testing. NYSHFA recommends looking at these specific areas.

New Emergency Preparedness Trends:

DOH reports the citations range from many to a few.  DOH will be sharing more information related to 1135 wavier as there have been many questions related to this. 

Here are a few deficiencies: no notification as it relates to residents and family regarding your EP plan, no revisions of the EP plan. NYSHFA encouraging providers to make sure all staff know about your EP plan and how to access it. See Appendix Z Emergency Prep and survey tool. Reach out to your community partners, fire department and EMS.  NYSHFA encourages members to take a look at resources available on our Emergency Preparedness and ROP pages. Additionally, a pre-conference session will be held at the Turning Stone Casino on May 2nd the topic will be Life Safety and Emergency Management.

C. Auris Update:

A total of 16 new facilities have been identified in the NYC region. The following are the areas that continue to an area of concern handwashing, personal protective equipment donning and doffing, Terminal cleaning, signage used not correct, policies and procedures out of date.

Currently a video is being developed in multiple language for the environmental services for cleaning. DOH is also observing and interviewing the Administrator and the DON and how they respond to violation of policies related to C. Auris. As audits continue letters are being mailed to the out to the administrators for follow-up. 

CMS Focused Schizophrenia Surveys:

CMS has completed three surveys of the five that were to be conducted. DOH have the results for two of those three surveys, the third is in process in the MARO region. These surveys are being treated as a complaint survey.

A number of tags have been cited 641, 644, 657, 745, 746, 758, 841. CMS is looking at the following areas during the survey: Demographics, Pre-assessment screens, evidence on Schizophrenia diagnosis on admission and documentation to support such, after admission screen level, persistent behaviors, gradual dose reduction, process for established diagnosis. Maximum sample size is 16 and two contracted surveyors will conduct these surveys.

CMS Directive F-600 Abuse / Neglect Citations:

DOH wanted providers to be aware the of the F-600 citation as it relates to Abuse/Neglect (Individual culpability versus facility). If there is a violation of care plan where there is injury there will be a citation of the F–600 tag.

Although staff violated the care plan and the facility may have completed supervision and education and other steps etc. the CMS directive is the facility cannot separate from the actions of their staff. DOH will continue to review cases on an individual basis and will be consulting with CMS as appropriate. NYSHFA raised concerns to the DOH regarding the citations of this tag. NYSHFA also discussed this with CMS Director Karen Tritz and again will discuss this at the AHCA meeting this week with David Wright. 


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