Division of ACF / Assisted Living Surveillance

Transcription

1 Division of ACF / Assisted Living Surveillance Valerie A. Deetz, Director June 27, 2017

2 June 27, Mission Statement The Division of Adult Care Facilities (ACF) and Assisted Living Surveillance will ensure that residents of New York State Adult Care Facilities receive high quality services through: Compliance with statutory and regulatory requirements; Promotion of innovative and technological practices; Quality assurance and improvement activities; and Fostering of continuous improvements through collaboration with key stakeholders.

3 June 27, Accomplishments and Division Goals

4 June 27, Accomplishments Awarded the final ALP solicitation under the original ALP 6000 legislation 3,530 beds awarded under the ALP ,358 to be operationalized within 24 months Issued EQUAL funds (252 ACFs on behalf of 12,047 residents) Issued the Operating Subsidy applications for funding to not-for-profit Enriched Housing (EH) Program Sponsors who provide board, care and services to low-income (SSI eligible) individuals based on the eligible resident count Continued review of ACF regulations and developed HCBS Transition Plan for ALPs Provided initial training to DOH and ACFs on the federal HCBS Settings requirements

5 June 27, Accomplishments cont. Updated Mandatory Reporting Forms (clarity and relevance) Completed statewide training for all DOH survey staff and ACFs on Achieving Sustainable Compliance and Outcomes, revised surveillance protocols and tools Developed and issued Guide for Quality Assurance/Improvement in ACFs Revised Incident Reporting Form to support improved outcomes related to QA/QI Developed and implemented Architectural Waiver Form (DOH 5226) Developed Plan of Correction (POC) Checklist to assist in the development of an acceptable POC

6 June 27, Division Goals Review and expedite processing of licensure applications; Update forms and schedules Advance Regulatory reform measures consistent with federal HCBS requirements Create system to collect Owner and Operator information to assist with the determination of an Operator in Good Standing (in process) Continue to monitor and improve consistency/standardization of surveillance functions Convene surveyor/stakeholder trainings focusing on HCBS compliance and case management Continue to increase provider communications and transparency Implement NYS Electronic Certificate of Need system (NYSE CON) for ACF licensure applications by end of year

7 June 27, Division Goals Implement Notification to Operate a Temporary Residential Services/ Respite Program (Completed) Issue revised closure guidelines (Completed) Redesign and update information on the NYS Department of Health Adult Care Facility/Assisted Living Website (In process) Revise regulations pertinent to Statement of Resident Rights & Responsibilities Issue New Administrator/ EHP Coordinator guidance (Completed) Develop DOH 30 Day Notice of Termination (In process)

8 June 27, Redefining Adult Care Facilities for the Twenty-first Century Members include: NYSDOH, Associations, Resident Advocacy Organizations, Administrators, NYS Ombudsman, Independent Living Organization, Justice Center, Residents Workgroup goals include: Streamline, clarify and reduce duplicity Develop recommendations to revise regulations to reflect the population, federal HCBS requirements and industry changes; and Incorporate policy interpretations, waivers, and equivalencies in the regulations as needed Next Steps: Advance Phase I recommendations and focus on revising environmental & architectural regulations consistent with the NYS Building Code and FGI

9 June 27, Redefining Adult Care Facilities for the Twenty-first Century Phase I 487.1/488.1 Applicability 487.2/488.2 Definitions (Adds definitions and clarity to commonly used terms) 487.3/488.3 General Provisions (Waivers and Equivalencies) 487.6/488.6 Resident Funds and Valuables 487.8/488.8 Food Service / Disaster & Emergency Preparedness (Elements of a disaster and emergency response plan)

10 June 27, Surveillance

11 June 27, Total number of surveys (Exit Date ) Complete: 88 Complaint: 219 Follow-Up: 44 Other: 58 Total surveys conducted in 2016: 1,590

12 June 27, Top 5 Citations (4 year cumulative) 487.7(f)(5) Medication Management. For residents in need of supervision and assistance, the operator shall establish a system for staff to: (i) provide the resident with proper dosage of medication at the designated time; and (ii) observe and record that the resident takes the medication (e)(2) Required Reports. The operator shall submit to the department: (2) A quarterly statistical information report (e)(1) Food Service/Sanitation The operator shall comply with regulations relating to food service for sanitation, safety and health, as set forth by the New York Sanitary Code (10 NYCRR Part 14) and other applicable county and local health codes (k)(1-3) Environmental Standards. (1) The operator of each facility shall insure the continued maintenance of the facility. (2) The building and grounds shall be maintained in a clean, orderly condition and in good repair. (3) All equipment and furnishings shall be maintained in a clean, orderly condition and in good working order.

13 June 27, Top 5 Citations (4 year cumulative) 487.7(g)(1)(ii-xiii) Case Management. (1) Case management services shall include: (ii) orientating a new resident and family to the daily routine; (iii) assisting each resident to adjust to life in the facility; (iv) assisting each resident to maintain family and community ties and to develop new ones; (v) encouraging resident participation in facility and community activities; (vi) establishing linkages with and arranging for services from public and private sources for income, health, mental health and social services; (vii) assisting residents in making application for, and maintaining, income entitlements and public benefits; (viii) assisting the resident in obtaining and maintaining a primary physician or source of medical care of choice, who is responsible for the overall management of the individual s health and mental health needs; (ix) assisting the resident in making arrangements to obtain services, examinations and reports needed to maintain or document the maintenance of the resident s health or mental health, including: (a) health and mental health services; (b) dental services; and (c) medications; (x) providing information and referral; (xi) coordinating the work of other case management and service providers within the facility; (xii) assisting residents in need of alternative living arrangements to make and execute sound discharge or transfer plans; and (xiii) assisting in the establishment and operation of a system to enable residents to participate in planning for change or improvement in facility operations and programs and to present grievances and recommendations.

14 Adult Home regulations June 27, TOP 5 CITATIONS (4 YEAR CUMULATIVE) Number of times cited 487.7(f)(5) (e)(2) 487.8(e)(1) (k)(1-3) 487.7(g)(1)(ii-xiii)

15 June 27, Complaint Allegations Records/Reports 3% Personal Care 5% Housekeeping 5% Resident Funds 5% Resident Termination 3% All Other 3% Environmental/Safety 3% Resident Rights 9% Abuse-All Incidents 5% Resident Deaths 1% Case Management 9% Facility Maintenance 9% Supervision 11% Dietary Standards 7% Medications 8% Admission/Retention 8% Personnel/Staffing 6%

16 June 27, Inspection Review Process (IRPs) 4/14-4/17 Changes, 18, 9% Expunged, 46, 23% Changes Upheld Expunged Upheld, 134, 68%

17 June 27, Inspection Review Process (IRPs): Breakdown by Year Upheld Expunged Changed

18 June 27, Program & Policy Updates

19 June 27, Efforts To Improve & Sustain Quality Holding Operators Accountable for maintaining compliance with requirements Working with poor performing facilities to effectuate sustainable improvements Statewide training series with a 2017 focus on Case Management with the goal of improved resident satisfaction and outcomes Strengthening Enforcement Remedies Developed New Administrator Checklist and Informational Guide, POC checklist and QA/QI guide

20 June 27, New Administrator Informational Guide Requirements for Administrator/ EHP Coordinators Newly approved administrators New establishments Change in Operators Roadmap for accessing applications on the Health Commerce System Overview of applications needed for Emergency Preparedness activities Mandated forms and reportable incidents Statewide Financial System (SFS) accounts Posted to the Health Commerce System as DAL 17-12

21 June 27, Home and Community-Based Setting Requirements Final rule promulgated in 2014 with expected date of full compliance by March 2022 Requires appropriate home and community based setting for Medicaid waiver programs including 1915(c),1915 (i) and the 1115 waiver which will include services provided by NYS Assisted Living Programs (ALPs) Ensures an individual s rights of privacy, dignity, respect, & freedom from coercion and restraint Optimizes individual initiative, autonomy, & independence in making life choices Facilitates individual choice regarding services & supports, and who provides them Is integrated in & supports access to the greater community

22 June 27, Current ALP Environment There are currently 138 licensed Assisted Living Program (ALPs) throughout New York State Capital District Regional Office 19 Central New York Regional Office 24 Metropolitan Area Regional Office 64 Western Regional Office

23 Number of ALP Beds June 27, Year Cumulative Count of Licensed ALP Beds 10,000 9,000 8,000 CUMULATIVE COUNT OF NEW ASSISTED LIVING PROGRAM BEDS BEGINNING JANUARY 1 Cumulative Count of New Assisted Living Program Beds 7,000 6,000 5,000 4,000 3,000 2,000 1, Calendar Year

24 June 27, DOH Transition Plan: Assisted Living Next Steps Continue to work with key stakeholders to develop proposals for statutory and regulatory amendments to foster conformance with the HCBS Settings requirements Anticipate final regulatory amendments no later than January 2019 Phase I proposals under agency review Provide ongoing guidance to promote compliance (HCBS Toolkit for ALP providers) Develop and release comprehensive Resident Service Plan form Surveillance Implement ACF Licensure checklist for all new ALPs to assess level of compliance with the HCBS Settings Rule Create survey tool and protocol to assess HCBS compliance

25 June 27, Justice Center 19 Adult Care Facilities are identified as being under the conjoined jurisdiction of the New York State Department of Health and the Justice Center for the Protection of People with Special Needs DSS-3123/DOH-5175 (Incident Report) is not accepted by the Justice Center as an appropriate reporting mechanism Code of Conduct must be reviewed by custodians at the time of their initial employment, and at least annually thereafter

26 June 27, EQUAL The EQUAL application was opened and posted to the Health Commerce System on May 11, 2017 as DAL The application must be electronically submitted by 5:00 pm on Friday, July 7, 2017 Prior to applying for EQUAL Program funds the facility is required to receive approval of its expenditure plan from the residents council for the facility It is recommended that the resident council adopt a process to identify the priorities of the residents for the use of the program funds and to document the residents top preferences by a means that may include a vote or survey

27 June 27, EQUAL The expenditure plan should detail how program funds will be used to improve the physical environment of the facility or the quality of care and services rendered to residents The facility s application for EQUAL must include a signed and dated attestation from the president or chair-person of the resident council or, in the absence of a resident council, at least 3 residents of the facility, stating that the application reflects the priorities of the residents of the facility The attestation must document the top 3 priorities of the residents and be ed to the EQUAL BML for the application to be complete Surveillance protocol in place to assess appropriate use of funds

28 June 27, Emergency Preparedness It is imperative that all roles identified on the Health Commerce System (HCS) be reviewed and up-to-date including relevant contact information contained in the Communications Directory. These include Emergency Office Roles, Emergency Response Coordinator, and efinds Reporting Administrator The 24 by 7 Contact should not be the facility number. It should a number reachable after business hours, or should the facility phone be not working Respond to Hospital Emergency Response Data Systems (HERDS) requests

29 June 27, efinds efinds Reporting Administrator role should be populated by staff on each shift; these staff should know where the scanner and wristbands are, and have access to them Procedures should match available staffing and demands of emergency; use exercises to train staff and refine procedures, such as with and without internet, with and without scanners, with and without notice; receiving and sending Exercises have shown that it takes about 3 minutes per person to apply wristband and enter data; should have paper copies of their resident list as back-up

30 June 27, efinds If localized evacuation, contact the NYSDOH to open an Operation to allow the use of efinds. If large-scale emergency, NYSDOH will alert facilities through HCS that they must use efinds For general assistance, questions, and additional wristbands: In the event of facility closure, please return the efinds scanner to DOH, now included in revised closure guidelines

31 June 27, Considerations for Chair-Fast Residents Similar to the ALP notification to DOH when accepting chairfast residents, please consider the following: Level of Cognition How many existing chair-fast residents does the facility have? What are the 24/7 staffing levels for the facility? Is the facility 100% sprinkled? Does the resident otherwise meet ALP retention standards? Where will the resident(s) be located within the building what floor? What is the amount of assistance the resident needs? Is the resident(s) able to self-propel their wheelchair? If not, what level of assistance is required? What is the facility s plan to meet the resident s physical, mental and psychosocial needs? Has the facility s evacuation plan been updated to reflect change in resident demographics?

32 June 27, Dear Administrator Letters 2017 to date DAL 17-01: 2016 ACF Annual Census Report DAL 17-02: Adult Care Facility Smoking Policies and Procedures (pending) DAL 17-03: ACF Legal Services Agencies and Community Resident Advocacy Services Guide DAL 17-04: Revised IRP Process DAL 17-05: A Resident s Guide to Department of Health Inspections (pending) DAL 17-06: Notification to Operate a Temporary Residential Services/Respite Program DAL 17-07: 1 st QSIR 2017 DAL 17-08: Revised Closure Guidelines DAL 17-09: Guidance for Assisted Living Programs to Comply with the Home and Community Based Settings (HCBS) Final Rule (pending) DAL 17-10: Enhancing the Quality of Adult Living (EQUAL) Program for SFY DAL 17-11: Warm Weather Advisory

33 June 27, Dear Administrator Letters 2017 to date DAL 17-12: New Administrator/EHP Program Coordinator and/or Operator Checklist and Informational Guide DAL 17-13: 2 nd QSIR 2017 (pending) DAL 17-14: ACF/Assisted Living 30 Day Notice of Termination Webinar: Achieving Sustainable Compliance: This webinar includes an overview of Quality Assurance, its application in Adult Care Facilities (ACF), and a review of the ACF statewide surveillance process and documentation tools (posted 2/2/17)

34 June 27, Developing Approvable Policies & Procedures

35 June 27, Policies and Procedures (NYSDOH Division of HCBS website) Policy: A predetermined course of action that is stated clearly and simply Used to set direction in an organization and assist in guiding decisions Procedure: Describes step-by-step instructions to accomplish the policy Identifies the staff person(s) responsible to implement and monitor the procedures Include sufficient clear detail that end users will easily understand how to comply

36 June 27, Guidance When Writing a Policy Information should be stated in an easy to read format Language should be clear and easily understood so that it can be retained and used Avoid lengthy complex information Remember your objective(s) Keep language specific to reflect the policy s intent so there is no misinterpretation Reference information from a credible source

37 June 27, Guidance When Writing a Policy cont. Suggested information to be included in each policy: Agency Name Title: Clear and concise Policy Statement/Purpose: Include a purpose which indicates the intent or objective of the policy Date: Policy date and revision date is clearly indicated Page Number: Number each page, e.g. 1 of 4 pages

38 June 27, Guidance When Writing a Policy cont. Information to consider when developing a policy: Authority: Reference to the guidance which governs the policy, statute or regulation Application: Who or what the policy applies to is clearly identified (e.g. new employees, food service staff) Responsible Party: Identify the Title, Position or Department Terminology: Is defined so that it is easily understood in context of the policy, e.g. authorized person or temporary employee are terms that must be defined in the CHRC policy

39 June 27, Guidance When Writing a Procedure Describe each step by step in the process and actions needed to comply with a policy (while policies guide decisions, procedures show how to complete the task or process) A well written procedure communicates effectively and should contain the following information: An overview of the procedure Identification of any necessary skills and/or materials needed A logical sequence of steps in the order they occur (steps should be clear, concise and easy to follow) Use diagrams, illustrations or examples, if appropriate, that may increase the clarify of the steps identified.

40 June 27, Policy Template Agency Name: Effective Date: Page Number: Revised Date: Policy Title: Statement/Purpose: Statement of purpose for the policy Authority: Reference to regulations, rules a/or policy directives that govern the policy Application: Who/What the policy applies to Terminology: Policy is defined, clear and easily understood Responsible Party: Title, Position or Department Procedure: Overview of Procedure if appropriate A. Identification of skills and/or materials needed B. Steps in the order they occur

41 June 27, COLLABORATION IS KEY THANK YOU FOR YOUR CONTINUED COMMITMENT TOWARDS ENHANCING THE QUALITY OF LIFE FOR OUR RESIDENTS!!!! WE LOOK FORWARD TO ONGOING COLLABORATION IN Phone: (Program) (Licensure)