Division of ACF / Assisted Living Surveillance Valerie A. Deetz, Director May 2, 2017
May 2, 2017 2 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.
May 2, 2017 3 2016-17 Accomplishments and Division Goals
May 2, 2017 4 2016 Accomplishments Awarded the final ALP solicitation under the original ALP 6000 legislation 3,530 beds awarded under the ALP 3400 3,358 to be operationalized within 24 months Issued EQUAL 2016-17 funds (252 ACFs on behalf of 12,047 residents) Issued the 2016-2017 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
May 2, 2017 5 2016 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
May 2, 2017 6 2017 2018 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 late-summer
May 2, 2017 7 2017 2018 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 (In process) Develop DOH Termination Notice (In process)
May 2, 2017 8 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
May 2, 2017 9 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 487.12/488.12 Disaster & Emergency Preparedness (Elements of a disaster and emergency response plan)
May 2, 2017 10 Surveillance
May 2, 2017 11 Total number of surveys (Exit Date 1.1.2016 12.31.2016) Complete: 306 Complaint: 808 Follow-Up: 241 Other: 235 Total surveys conducted in 2016: 1,590
May 2, 2017 12 Top 5 Common Citations 1. Resident Services Medication, Case Management, Supervision 2. Environmental Standards Maintenance of building, grounds, and equipment, housekeeping (including vermin), smoke, fire protection 3. Records and Reports Maintenance and availability of resident records 4. Food Service Food purchasing, storage, and preparations, prescribed diets and food allergies 5. Admission Standards Admission criteria, medical evaluations, mental health evaluations, & persistent efforts
May 2, 2017 13 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%
May 2, 2017 14 Inspection Review Process (IRPs) Changes, 18, 9% Expunged, 46, 23% Changes Upheld Expunged Upheld, 134, 68%
May 2, 2017 15 Inspection Review Process (IRPs): Breakdown by Year 100 90 80 70 60 50 40 30 20 10 0 2015 2016 2017 Upheld Expunged Changed
May 2, 2017 16 Program& Policy Updates
May 2, 2017 17 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
May 2, 2017 18 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
May 2, 2017 19 ACF Occupancy Percentages (Self-Reported) 90% 85% 85% 80% 80% 81% 78% 79% 77% 77% 79% 80% 80% 74% 71% 70% 67% 68% 61% 60% 54% 51% 50% 40% 30% 20% 10% 0% Total Beds ALP Non-ALP ALR EALR SNALR 2014 2015 2016
May 2, 2017 20 Home and Community-Based Setting Requirements Final rule promulgated in 2014 with expected date of full compliance by March 2019 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;
May 2, 2017 21 Current ALP Environment There are currently 135 licensed Assisted Living Program (ALPs) throughout New York State Capital District Regional Office 19 Central New York Regional Office 24 Metropolitan Area Regional Office 62 Western Regional Office 30 0 10 20 30 40 50 60 70
Number of ALP Beds May 2, 2017 22 12 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 1,000 0 1990 1995 2000 2005 2010 2015 2020 Calendar Year
May 2, 2017 23 2016 ALP HCBS Self-Assessment Results 1.The facility s policies and procedures optimize HCBS compliance: Yes (49%) No (43%) Limited (8%) 2. If you have a Special Needs Assisted Living Residence (SNALR), are Assisted Living Program (ALP) services provided in your SNALR? Yes (9%) No (39%) N/A (52%) 3. Is the ALP on the same grounds of, or in the same building as, or adjacent to, a nursing home? Yes (26%) No (74%) 4. If yes, does the setting serve to isolate the resident from the broader community, or otherwise have the characteristics of an institution, or fail to meet the characteristics of a home and communitybased setting? No (91%) Limited (9%) 5. Each ALP resident has a person-centered care plan that documents, for example, that the resident has a choice of residential settings. Yes (70%) No (30%) 6. Each resident's rights (freedom and support) to control his/her daily schedule and activities are optimized. Yes (95%) No/Limited (5%) 7. The facility is located close to public transportation. Yes (75%) No (25%)
May 2, 2017 24 2016 ALP HCBS Self-Assessment Results (Continued) 8. Each resident receives services in the community to the same degree of access as residents not receiving ALP services:? Yes (93%) No/Limited (7%) 9. Each resident is provided the opportunity to engage in community life event/activities outside of the facility (for example, facility provides informational flyers, off-site trips, or announcements of upcoming community events): Yes (89%) No/Limited (11%) 10. Each resident s initiative, autonomy, and independence in making decisions related to their physical environment are optimized. Yes (92%) No/Limited (8%) 11. Resident rights are ensured, including privacy, dignity, respect, and freedom from coercion and restraint. Yes (98%) No/Limited (2%) 12. Each resident s choices regarding services (for example, medical providers, mental health services, and day programs), and who provides them, including service providers and programs in the greater community, are facilitated. Yes (93%) No/Limited (7%)
May 2, 2017 25 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
May 2, 2017 26 Justice Center (20 ACFs) Entities must contact the Justice Center to request a check of the Staff Exclusion List (SEL) before determining whether to hire or otherwise allow any person with the potential to have regular and substantial contact with a service recipient. Any person can include an employee, administrator, consultant, intern, volunteer, or contractor. An inquiry of the Statewide Central Register of Child Abuse and Maltreatment (SCR) must be conducted.
May 2, 2017 27 EQUAL The 2017-2018 EQUAL application will be an electronic application accessed through the HCS. The application is anticipated to be available in April pending availability of funds 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
May 2, 2017 28 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 emailed to the EQUAL BML for the application to be complete Surveillance protocol in place to assess appropriate use of funds
May 2, 2017 29 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
May 2, 2017 30 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
May 2, 2017 31 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: efinds@health.ny.gov In the event of facility closure, please return the efinds scanner to DOH.
May 2, 2017 32 Policies and Procedures 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
May 2, 2017 33 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
May 2, 2017 34 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
May 2, 2017 35 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.
May 2, 2017 36 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.
May 2, 2017 37 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
May 2, 2017 38 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 chairfast residents does the facility have? What are the 24/7 staffing levels for the facility? Is the facility 100% sprinklered? 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?
May 2, 2017 39 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 2017-2018 (pending)
May 2, 2017 40 Open Discussion Mandatory ACF Annual and Quarterly Reports Annual Financial Statement Annual and Quarterly Statistical Information Reports HERDS response (Critical Asset Survey due ) CHRC Reimbursement Mail Delivery Medication Management (reorders, omissions, principles) Case Management Revising care plans, treatment plans, ISPs POCs HCS Accounts
May 2, 2017 41 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 2017. Phone: 518-408-1133 (Program) 518-408-1624 (Licensure) Email: acfinfo@health.ny.gov