Valerie A. Deetz, Director Timothy Perry-Coon, Deputy Director Dot Persico, R.N.

Transcription

1 NYS Department of Health Divisions of ACF &Assisted Living Surveillance and the Community Transitions Program Valerie A. Deetz, Director Timothy Perry-Coon, Deputy Director Dot Persico, R.N.

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

3 2014 Accomplishments Streamlined Reporting of Annual Census Streamlined the ACF Licensure Application and provided statewide training to stakeholders on the revised application forms and processes Implemented Electronic Statements of Deficiencies Implemented Quarterly Statistical Information Reports (QSIRs) Announced ALP 4500 Conversion Initiative Implemented an Electronic EQUAL Application Initiated review of Adult Care Facility regulations Updated Mandatory Reporting Forms Developing guidance for implementation of the Criminal History Record Check Program. (Webinars scheduled for December 16 th and December 17 th )

4 Division Goals Expedite processing of licensure applications Increase consistency/standardization of surveillance functions Implement CHRC Program for ACFs Convene regulatory review workgroup with internal and external stakeholders Continue to increase Provider communications (Association) Continue to automate communications to ACFs

5 Ongoing Efforts To Improve Quality Ensuring surveillance activities have impact on achieving sustainable improvements in performance. Working with Adult Care Facilities that have repeat deficiencies and/or serious concerns to facilitate improvements. Effectively using Directed Plans of Correction as a quality improvement tool. Holding Leaders Accountable.

6 Surveillance Total number of surveys (Exit Date 11/01/ /31/2014) Complete: 306 Complaint: 895 Follow-Up: 202 Other: 88 Total surveys conducted: 1, Total Surveys Conducted: 1,362 *Exit Date 01/01/ /31/2013

7 Surveillance Cont. Complete Inspections 2011: 329 inspections/1,037 Violations or 3.2 Violations per inspection 2012: 2013: 283 inspections/860 Violations or 3 Violations per inspection 275 inspections/934 violations or 3.4 violations per inspection

8 Surveillance: Most Common Citations Resident Services: 729 Medication & case management & supervision Environmental Standards: 543 Maintenance of building, grounds & equipment, housekeeping (including vermin) & smoke & fire protection Food Service: 290 Food Purchasing, storage & preparations, prescribed diets & food allergies Admission Standards: 168 Retaining individuals beyond retention standards, medical and mental health evaluations not completed Personnel: 149 Trained in basic first aid & employee health statement

9 Surveillance: Most Common Citations Records and Reports: 122 Maintenance & availability of resident records Resident Services: 116 Supervision, Medication Management, Storage of Medications, Case Management Disaster and emergency planning: 72 Fire dills & approved written disaster plan Resident Protections: 69 Courteous, fair & respectful treatment & executing admission agreements Admission and Retention Standards: 64 Inappropriate admission TOTAL: 1,315 violations or an average of 1.9 violations per survey (2014 to date)

10 Division of ACF/Assisted Living Updates Creation of ACF/Assisted Living Surveillance Committee to review existing surveillance policies & procedures and identify areas for potential revisions to: Facilitate a quality survey; Meet existing state regulatory requirements; and Optimize efficiencies in the surveillance process Review of the survey process will include but not be limited to: Team composition Sample size selection Record review procedure and criteria Resident interview procedure Content & format of survey reports (Statement of Deficiencies) The committee is comprised of statewide surveillance staff and central office program staff The committee will present recommendations to central and regional office leadership for review and approval by late summer.

11 EQUAL- Enhancing the Quality of Adult Living Total anticipated appropriation for SFY EQUAL is $6,532,000 The EQUAL application was converted to an electronic application that was accessed through the Health Commerce System 263 applications received with 11 declinations for a total of 274 responses as compared to 231 Supplemental Security Income (SSI)/Safety Net residents (SN) residents residing in facilities receiving EQUAL funds will benefit Applicants were required to engage the Resident Council in discussions for the purposes of utilizing funds consistent with their desires Surveillance protocol in place to assess appropriate use of funds

12 Justice Center Update 32 ACF's under the conjoined jurisdiction of the New York State Department of Health and NYS Justice Center for the Protection of People with Special Needs that meet the following criteria: 80 beds or more 25% SMI or greater Fewer than 55% beds designated as Assisted Living Program beds Investigation updates: 14 NYCRR Part 702 authorizes collection of Social Security Numbers (SSN) or Alien Registration Number (ARN) for custodians identified as suspects in reportable incidents. DOH may collect this information as a delegate investigatory entity SSNs/ARNs will be used to verify identity To date, over 2,933 referrals to DOH. Justice Center guidance (collection of SSNs)

13 New York State Department of Health Adult Care Facility Surveillance Central Complaint Hotline The Division of Adult Care Facility/Assisted Living Surveillance is responsible for investigating written and/or verbal complaints received by the ACF Central Complaint Hotline concerning both licensed and unlicensed adult care facilities. Complaints are triaged on intake and assigned a level of severity which determines the timeframe in which the complaint is investigated. All relevant information provided is entered into the Aspen Complaint and Incident Tracking System (ACTS) and assigned to one of the Department s four regional offices for investigation. The results and findings of each investigation are then documented in the ACTS database. The ACF Central Complaint Hotline is answered by ACF staff from 8:45 AM to 4:45 PM Monday through Friday, excluding holidays. Complaints made after hours are left on the hotline voic system and retrieved the next morning. The voice mail account is also checked twice weekends and holidays. Complaints received during these times which have been determined to be of an emergency nature will be immediately referred to the regional office contact person.

14 New York State Department of Health Adult Care Facility Surveillance Central Complaint Hotline Commenced Operation: 11/15/02 Total Number of Hotline Staff: 3 Additional Assignment: Home Care Information Hotline Total Complaints Processed through 6/30/14: 11,649 Total Allegations Reported through 6/30/14: 30,506 Average Allegations per Complaint through 6/30/14: 2.6

15 Complaint Allegations /30/2014 Resident Termination 3% All Others 3% Records/Reports 3% Personal Care 6% Environmental 3% Resident Rights 9% Abuse-All 4% Resident Death 1% Housekeeping 5% Resident Funds 5% Facility Maintenance 9% Case Management 9% Supervision 11% Dietary Menu Plans 7% Medications 8% Personnel 7% Admission/Retention 8%

16 Emergency Preparedness Update Ebola preparedness and oversight is the current main focus. No current patients with Ebola, as of 11/17/14, but preparations and precautions are ongoing. All hospitals have been assessed at least once for their ability to stabilize patients who are suspected of having Ebola, and then sending them to one of the 10 hospitals in NYS designated for ongoing Ebola care. Primary care clinics are currently being assessed for intake and triage protocols. Multiple-level screening of air passengers from countries with Ebola outbreak is ongoing at JFK airport. All air travel from those countries into NYS are routed to JFK. Passengers from these countries are followed by Local Health Departments twice a day. Guidance document is forthcoming.

17 Emergency Preparedness Update Any questions may be submitted to: For further information: Reminder: Please routinely check the Health Commerce System for updates and verify that all roles are updated as necessary. Keep all contact information current. Do not hesitate to contact your Local Health Department (LHD) and your Regional Office leads with any questions.

18 Emergency Preparedness Update Coastal storm preparations are ongoing, including gathering information on facility profiles of readiness, send-receive arrangements, and business continuity plans in case of evacuation. The Associations, NYCDOHMH and NYSDOH are working with operators to make plans for possible alternate evacuation sites (other than evacuation to another ACF). Webinars are planned for January 2015 for training on use of new Transportation Assistance Levels (TALs). Final dates and plans will be issued mid-december The guidance document is under review.

19 Safe Recordkeeping Operators are responsible to have policies and procedures in place to ensure that resident and facility records, under their custody, are: Stored in a secure location which maintains the physical integrity of the records Safeguarded from the potential for environmental damage. Take the appropriate action to save the records in accordance with the various record retention requirements.

20 Dear Administrator Letters Issued (1/1/ Present) DAL 14-01: Individualized Service Plan and EHP Individualized Service Plan Addendum for Annual Resident Evaluations (posted 10/30/14) DAL 14-02: 2013 ACF Annual Census Report (posted 3/28/14) DAL 14-03: EQUAL (posted 1/28/14) DAL 14-04: Supplemental Compliance Plan (posted 1/31/14) DAL 14-05: Revised ACF DSS Forms: 934, 2853, 2854, 2855 and 3027 (posted 8/21/14) DAL 14-06: Revised ACF Closure Guidelines (posted 3/20/14) DAL 14-07: ALP Chair fast Bill (posted 11/14/14)) DAL 14:08: Revised List of Transitional Adult Homes (posted 9/30/14) DAL 14-09: UAS FAQs (posted 5/12/14) DAL 14-10: Revised ALP Medical Evaluation DSS-4568 (posted 5/8/14) DAL 14-11: Safe Record Keeping (pending) DAL 14-12: Amendment of Regulations: 487.4, and (posted 5/8/14) DAL 14-13: Common Application (posted 8/22/14) DAL 14-14: EALR Q&As (posted 6/26/14) DAL 14-15: Warm Weather Advisory (posted 7/2/14)

21 Dear Administrator Letters Issued (1/1/2014- Present) DAL 14-16: 1 st /2 nd Quarter 2014 QSIR & Roster of Adult Home Residents (posted 8/8/14) DAL 14-17: Revised ACF DSS Forms: 2900 and 3026 and DOH Form 4235 (pending) DAL 14-18: ACF Legal Services Agencies and Community Resources Providing Resident Advocacy Services Guide (posted 10/22/14) DAL 14-20: 3 rd Quarter 2014 QSIR & Roster of Adult Home Residents (posted 10/16/14) DAL 14-21: EQUAL Program for SFY (posted 10/8/14) DAL 14-22: Case Management Services (posted 10/8/14) DAL 14-23: Transition to State Supplemental Payment for SSI (posted 10/29/14) DAL 14-24: 2013 ACF Financial Reports (posted 10/16/14) DAL 14-25: Ebola Guidance (pending) DAL 14-26: Revised List of Transitional Adult Homes (posted 11/4/14)

22 BRIEF CHRC OVERVIEW 22

23 Criminal History Record Check Program (CHRC) Policies and Procedures To Include: Determining who is subject Retaining Consent forms (CHRC 102) Supervising employees while awaiting results Reporting employee terminations and separations Timeliness of scheduling fingerprint appointments and rescheduling when needed. Recognition that charging costs to employees is not permitted

24 Common Terms in CHRC 24 HCS - Health Commerce System AP - Authorized Person AR Agency Representative Temporary/Provisional employee Initial vs expedited submission DCJS (Division of Criminal Justice Services) Rejections/resubmissions Non-Idents/Idents LiveScan and IdentoGO by MorphoTrust USA

25 CHRC Policies and Procedures Must Include: 25 Determining who is subject Retaining Consent forms (CHRC 102) Supervising employees while awaiting results Reporting employee terminations and separations Timeliness of scheduling fingerprint appointments and rescheduling when needed. Charging costs to employees is not permitted

26 Who is Subject to CHRC? 26 All non-licensed employees providing direct care to residents/clients pursuant to a plan of care, including those who have access to living quarters. Examples: - PCAs - Hairdressers & barbers - HHAs - Housekeepers - Dietary Aides - Maintenance workers

27 Who is Not Subject to CHRC 27 Licensed health care employees Article 8 of the Education Law Nursing home administrators Article 28-D of the Public Health Law Employees without resident contact Groundskeepers, kitchen workers, etc. Volunteers

28 COLLABORATION IS KEY THANK YOU FOR YOUR CONTINUED COMMITMENT TOWARDS ENHANCING THE QUALITY OF LIFE FOR OUR RESIDENTS!!!! WE LOOK FORWARD TO CONTINUING OUR PARTNERSHIP WITH YOU IN Phone: (Program) (Licensure) (CT Program) For questions related to the CHRC Program 28