NYS SADC Heightened Scrutiny Submission

The New York State (NYS) Department of Health (DOH), in order to be in compliance with 42 CFR §441.301(c)(5)(v), is seeking public comment on the Heightened Scrutiny evidence packets which are required as part of the Statewide Transition Plan (STP) for coming into compliance with the Home and Community-Based Services (HCBS) Settings Final Rule for all Social Adult Day Care (SADC) sites.

For the full announcement and details on submitting a public comment, please see the following:

  • Announcement: NYS SADC Heightened Scrutiny Submission Avialable for Public Comment Until May 17, 2024 - (Web) - (PDF)

SADC Sites Categorized as Heightened Scrutiny

The following is a list of SADC sites identified and categorized as requiring Heightened Scrutiny, including the prong, a summary of how each site has or will overcome the presumption that it is an institution, and the state’s plan for oversight of remediation to ensure compliance with the settings criteria by the end of the transition period:

# SADC Site Prong Summary Submission
1 Chenango Valley Adult Enrichment Center 2 Per observation from the virtual onsite review, interviews with SADC staff, and desk review of the SADC person-centered service plan, the SADC site was identified as having the following isolating characteristics: Participant rights documentation states members are free from "unnecessary restraints", but restraints should never be used. The Member Rights document states the member "participates" in the PCSP process, and the submitted policy and procedures states members care plan is written "in conjunction with" the member. The HCBS Final Rule requires that the process is "driven" by the member, not that the PCSP be done only "in conjunction with" the member, and the process cannot be led by the SADC. The SADC PCSP template lacks a section to indicate necessary modifications. The SADC lacks notices for community integration and volunteer or employment opportunities. The SADC employs female staff only, which does not allow for member preferences to be accommodated. Remediation efforts will be concluded by 08/24/2023 and include updating policies and procedures to offer community activities and provide job/volunteer postings. Staffing requirements in relation to DOH guidelines will be updated to ensure proper staff-member ratio and so as to offer member- choice of staffing gender to assist with any personal needs. Revise Participant Rights document and any other associated policy/procedure to reflect that restraints not be used in any situation. Revise language within Member Rights document and any pertinent policies/procedures to address that member's should be driving their PCSP with assistance from the SADC staff, and including a section to document modifications to the freedoms allotted to all members via the HCBS Final Rule. 01-Chenango Valley Adult Enrichment Center (PDF)
2 Fort Hudson Social Day 1 The SADC site was identified as having the following isolating characteristics via the virtual on-site review, which included a PCSP review, and validation of any member experience surveys conducted by the MLTC plan: The SADC PCSP does not indicate any community integration options being offered to the members, SADC does not maintain members rights to privacy and dignity in that there are no male staff employed at the facility, the PCSP does not have a section to indicate any necessary modifications. Remediation efforts will be concluded by 09/20/2023 and include: Obtaining input from members about community integration activities at monthly formal council meetings and by using suggestion boxes. Staff will provide needed supports for members to participate in selected community integration activities. A section will be added to the PCSP where modifications and justifications can be documented, and the SADC will begin efforts to recruit a male PCA. 02-Fort Hudson Social Day (PDF)
3 Riverstone Senior Life Services 2 The SADC site was identified as having the following isolating characteristics, via the virtual on-site review, which included a PCSP review, and validation of any member experience surveys conducted by the MLTC plan: the SADC PCSP did not list community integration opportunities, did not list member's staff preference, states the member as being a 'part of' their PCSP process, and did not list community supports. There is no documentation that members have a right to handle their own funds, choose their preferred staff to provide services, have activities adapted to their abilities, or to have flexible mealtimes. In addition, there is no process documented on how staff are kept up to date on members' preference and needs, or how members can make them known. The Policy and Procedure manual contains the language "free from 'unnecessary' harm", which is not compliant with the HCBS Final Rule, there is no procedure for handling disruptive behavior, and the information in the Visitor Policy and the Visitor posting do not align. The front door is locked at all times, not allowing members to come and go as they please. Remediation efforts will be concluded by 9/30/2023 and include conducting morning meetings with members to obtain their feedback/suggestions, revise the Member Rights policy to include having access to their own funds, will develop a procedure for handling disruptive behavior, and will exclude the language free from 'unnecessary' harm from the Policy and Procedure manual. The SADC will ensure the front door can be accessed by all individuals entering and leaving, conduct daily staff meetings to ensure staff are kept up to date on the members needs and preferences, signs will be posted to indicate mealtime flexibility and how activities can be adapted to meet members' needs. The Visitor Policy will be updated to remove COVID related restrictions, the PCSP will include community integration options, member's preferences for staff, revise the language to state the PCSP process is driven by the member, include necessary supports and activity adaptions when required. 03-Riverstone Senior Life Services (PDF)
4 Carmel Richmond Health Care & Rehabilitation 1 The SADC site was identified as having the following isolating characteristics, via the virtual on-site review, which included a PCSP review, and validation of any member experience surveys conducted by the MLTC plan: The SADC representatives confirm that members have flexibility in their daily schedule, however there is no documentation to show how members are informed of their flexibility or choices. Remediation efforts will be concluded by 09/26/2023 and include: the SADC will post a notice informing members they can choose their activities and update its member rights document to indicate members have the right to change their schedule to any day or time of the week. 04-Carmel Richmond Health Care & Rehabilitation (PDF)
5 St. Vincent's De Paul Senior Life 1 The SADC site was identified as having the following isolating characteristics, via the virtual on-site review, which included a PCSP review, and validation of any member experience surveys conducted by the MLTC plan: The staff have not been trained in HCBS Final Rule standards. The Members Rights document states in several sections that the member has the right "to participate" in the PCSP process when the process should be directed by the member. The HCBS Final Rule requires that the process be "driven" by the member, not that the member is just participating, and the process cannot be led by the SADC. Remediation efforts will be concluded by 08/31/2023 and includes providing new hire training for all staff in topics such as PCSP, HCBS, personal care skills, supervision and monitoring, and will maintain training logs. The SADC Policy and Procedure manual will be updated to ensure the member is driving the plan of care, and update the language to reflect it. 05-St. Vincent's De Paul Senior Life (PDF)
6 Saint Cabrini 1 The SADC site was identified as having the following isolating characteristics, via the virtual on-site review, which included a PCSP review, and validation of any member experience surveys conducted by the MLTC plan: The setting did not have any volunteer or employment opportunities available to members, the Members Rights document indicates the member is able to choose who provides their services however, there are no male staff employed for members to choose if preferred. The PCSP policy indicates non-compliance because it states the PCSP will be "written for each participant"; the participants must drive their care planning process. The PCSP template does not have a section to document any modifications to the member's rights under the HCBS Final Rule and justification for the modification. There is no documented evidence of when company policies are reviewed or when the last update was made, if HCBS specific trainings were completed, or how the SADC ensures that one or more person's behavior does not impede on the rights of others. Remediation efforts will be concluded by 9/1/2023 and include reviewing and updating all policies and procedures including those related to behavior management procedures, identifying trainings available specific to HCBS Final Rule requirements, hiring a male staff member, updating the PCSP template to reflect the member is driving the plan of care and included a section for modifications, and posting volunteer and employment opportunities. 06-Saint Cabrini (PDF)