PUBLIC NOTICE: NYS DOH, Office of Aging and Long-Term Care, Bureau of Quality Assurance and Surveillance - ADHCP - Heightened Scrutiny Evidence Packets
In compliance with 42 CFR §441.301(c)(5)(v), NYS DOH, Office of Aging and Long Term Care, Bureau of Quality Assurance and Surveillance Adult Day Healthcare Program (ADHCP) is pleased to announce that it will conduct a public comment period, to allow members of the public to provide comments on its Home and Community-Based Services (HCBS) Final Rule related Heightened Scrutiny evidence packet(s), developed by NYS DOH, Office of Aging and Long Term Care, Bureau of Quality Assurance and Surveillance - ADHCP and New York State entities that oversee HCBS. This is being done to maintain federal match funding for home and community-based service setting(s) that NYS DOH, Office of Aging and Long-Term Care, Bureau of Quality Assurance and Surveillance - ADHCP has determined can or will overcome the institutional (i.e., non-eligible for HCBS funding) presumption by Department of Health and Human Services (DHHS), on or before March 17, 2023. ADHCP is a non-residential setting and there are 115 ADHCPs statewide. All programs were temporarily closed due to the pandemic. To date, 49 Programs have reopened. Heightened Scrutiny is requested for 49 ADHCPs that self-reported having at least one registrant that receives Medicaid-funded home and community-based services in their setting that is located within the nursing home or in the grounds of a public institution. Interviews, record reviews and observations were conducted through virtual tours at each of the facilities from 2021-2022 to assess for Rule compliance and the need for remediation.
The Heightened Scrutiny Evidence Packets have been posted on the New York State Register at https://dos.ny.gov/system/files/documents/2023/01/012523.pdf. This notice further serves to open the 30-day public comment period that will close on March 11, 2023. In addition to this 30-day comment period where the public will be afforded the opportunity to provide written comments, the Bureau of Quality Assurance and Surveillance will receive written comments by contacting via email: ADHCP.HCBS@health.ny.gov and/or by mail: Bureau of Quality Assurance and Surveillance - ADHCP, Division of Nursing Homes and ICF/IID Surveillance, New York State Department of Health - 875 Central Avenue Albany, NY 12206.
Heightened Scrutiny Overview
In accordance with federal rules set forth by the Centers for Medicare & Medicaid Services (CMS), the New York State Department of Health for Adult Day Health Care Program (ADHCP) is required to publish for public comment a list of Heightened Scrutiny settings that deliver Home and Community-Based Services (HCBS).
Strategies to Identify Settings
Heightened Scrutiny is a review of certain settings that, according to CMS, are presumed to be institutional in nature but do, in fact, demonstrate qualities of home and community-based settings. The ADHCP, which is a non-residential setting, conducted a series of program self-assessments based on "CMS Exploratory Questions to Assist States in the Assessment of Non-Residential Settings" against the standards of the HCBS Final Rule. NYS DOH assessed all reopened programs (post pandemic) for HCBS compliance through Self-Assessment Surveys, record reviews, virtual site reviews including interviews of staff, reviewing pictures of the buildings and signage to the program, checking program addresses for accuracy and google maps images of locations.
Strategies to Review Settings
NYS DOH worked with the providers of settings requiring a Heightened Scrutiny review to achieve HCBS compliance or to develop a plan to achieve HCBS compliance. Reviews conducted by DOH included but were not limited to record reviews, registrant/staff interviews, and observations made during virtual tour of all reopened programs. Each standard of the HCBS Final rule was analyzed, discussed with the facility management and staff. Programs that needed remediation were identified. General guidance and training were provided to program staff to meet compliance. Policies and procedures and any remediation completed by the program to meet compliance were filed within the program's file for reference.
Heightened Scrutiny Categories and Summary
CMS has identified three categories/prongs of settings that are presumed to have qualities of an institution. The categories are described below as well as the number of settings in each category that have been identified by OPWDD as requiring a Heightened Scrutiny review.
| Heightened Scrutiny Prong | Number of sites |
|---|---|
| Prong 1- Settings in this category are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment. | 30 |
| Prong 2 - Settings in this category are located in a building located on the grounds of, or immediately adjacent to, a public institution. | 6 |
| Prong 3- Settings in this category may have the effect of isolating individuals from the broader community.
|
13 |
Process for Applying CMS Feedback on Specific Settings
Heightened Scrutiny summaries, including public comment and supporting evidence, may later be selected for review by CMS as a part of a random sample. NYS DOH will use any feedback from the CMS random sample review to inform whether it is applicable to similarly situated settings and additional review and/or if remediation of settings not included in the CMS review sample is necessary.
Numbered List of Settings
The following is a list of all reopened ADHCPs identified and categorized as requiring Heightened Scrutiny, including the prong, a summary of how each setting 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:
| # | Facility Name | Prong | Summary |
|---|---|---|---|
| 1 | ADHCP #1 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan. Program has scheduled community events. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 2 | ADHCP #2 | 1 | Remediation was completed for policies and practices for person centered plan and separation of services from the nursing home. Staff are trained in the HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024 |
| 3 | ADHCP #3 | 2 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. All ADHC staff have been in-serviced in regard to HCBS and ADHC policies. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Program meets compliance. |
| 4 | ADHCP #4 | 2 | Remediation was completed for policies. Program revised their policies and practices for person centered plan and other HCBS requirements. All ADHC staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024 |
| 5 | ADHCP #5 | 3 | Remediation was completed in the following areas: Freedom to move bout in the program, Person-Centered Care Planning Process, and visitation policy. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. Program meets compliance. |
| 6 | ADHCP #6 | 2 | Remediation was completed to all policies pertaining to HCBS. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024 |
| 7 | ADHCP #7 | 1 | Remediation was completed to Policies and practices for person centered plan and separation of services from the nursing home and are up to date. Staff are trained in the ADHC policies and HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024. |
| 8 | ADHCP #9 | 3 | Remediation was completed to allow residents' choice/preference and choices policies. Staff at the ADHC are trained to the ADHC policies and HCBS requirements. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 9 | ADHCP #10 | 1 | Remediation in progress. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space or other administrative functions with the nursing facility. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 10 | ADHCP #11 | 1 | Remediation completed in regard to various policies. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space or other administrative functions with the nursing facility. Staff working at ADHCP are HCBS and ADHC policies trained. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024. |
| 11 | ADHCP #12 | 1 | Remediation was completed to all policies. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are a constraint. Remediation in progress. Targeted to be in compliance by 7/1//2024. |
| 12 | ADHCP #13 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan. Program has scheduled community events. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program will arrange alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 13 | ADHCP #14 | 3 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Remediation in progress. Targeted to be in compliance by 7/1//2024 |
| 14 | ADHCP #15 | 3 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Remediation in progress. Targeted to be in compliance by 7/1//2024. |
| 15 | ADHCP #16 | 1 | Remediation in progress. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 16 | ADHCP #17 | 1 | Remediation was needed to incorporate key features of the HCBS Final Rule with regard to person-centered planning. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 17 | ADHCP #18 | 1 | Remediation was done to all policies. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 18 | ADHCP #19 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. This setting is in the nursing home campus, and all ADHCP staff are trained in HCBS and ADHCP policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 19 | ADHCP #20 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the nursing facility. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 20 | ADHCP #21 | 3 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 21 | ADHCP #22 | 3 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Remediation in progress. Targeted to be in compliance by 7/1//2024. |
| 22 | ADHCP #23 | 3 | Remediation was completed to all policies pertaining to HCBS. Staff at the ADHC are trained to the ADHC policies and HCBS requirements. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 23 | ADHCP #24 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 24 | ADHCP #25 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space or other administrative functions with the nursing facility. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 25 | ADHCP #26 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 26 | ADHCP #27 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 27 | ADHCP #28 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 28 | ADHCP #29 | 1 | Remediation in progress. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff working at ADHCP are HCBS and ADHC policies trained. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 29 | ADHCP #30 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Staff have been in-serviced in regard to HCBS and ADHC policies. There is a clear separation from the nursing home and the program. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 30 | ADHCP #31 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor Community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 31 | ADHCP #32 | 1 | Remediation was completed. Program was sharing staff and administrative functions from the nursing facility. Program revised their policies and practices for person centered plan and other HCBS requirements separating policies from the nursing facility. Program does not share office space, staff, or other administrative functions with the nursing facility at this time. Staff have received in-services in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 32 | ADHCP #33 | 1 | Remediation was completed to allow residents choice/preference and choices policies. Staff at the ADHC are trained to the ADHC policies and HCBS requirements. Program does not share office space, staff, or other administrative functions with the nursing facility. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 33 | ADHCP #34 | 1 | This Program is surveyed by the Department of Health - Office of Public Health AIDS Institute. |
| 34 | ADHCP #35 | 2 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 35 | ADHCP #36 | 3 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 36 | ADHCP #37 | 1 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 37 | ADHCP #38 | 2 | Remediation was completed to all policies pertaining to HCBS. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 38 | ADHCP #39 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 39 | ADHCP #40 | 2 | Remediation was completed to all policies pertaining to HCBS. Staff at the ADHC are trained to the ADHC policies and HCBS requirements. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 40 | ADHCP #41 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 41 | ADHCP #42 | 1 | This Program is surveyed by the Department of Health - Office of Public Health AIDS Institute. |
| 42 | ADHCP #43 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Located within the nursing home but program does not share office space, staff, or other administrative functions with the nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 43 | ADHCP #44 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 44 | ADHCP #45 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Registrants are assessed to include opportunities to seek employment within the community. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Regular outdoor community activities scheduled. Program arranges alternative transportation methods for individuals to pursue community activities that reflect individual preferences. Program meets compliance. |
| 45 | ADHCP #47 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 46 | ADHCP #48 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 47 | ADHCP #49 | 1 | Remediation in progress. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 48 | ADHCP #50 | 1 | Remediation was completed to all policies pertaining to HCBS. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the co located nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
| 49 | ADHCP #51 | 1 | Remediation was completed. Program revised their policies and practices for person centered plan and other HCBS requirements. Program does not share office space, staff, or other administrative functions with the nursing facility. Staff have been in-serviced in regard to HCBS and ADHC policies. Rights of privacy, dignity, respect and freedom from coercion and restraint are maintained. Registrants are assessed to include opportunities to seek employment within the community. Planned outdoor community activities are being scheduled after the pandemic and reopening. Program needs to offer regular opportunities for registrants to go out into the community. Staffing and transportation issues are still a constraint. Program meets partial compliance. Targeted to be in compliance by 7/1//2024. |
Number of Settings That Cannot Overcome the Presumption:
None.
A List of Presumptively Institutional Due to Isolation
None.
Contact Information to Submit Public Comment
A draft of the Heightened Scrutiny evidence data packet(s) will be available for review at: https://regs.health.ny.gov/volume-c-title-10/1472732205/part-425-adult-day-health-care.
For individuals with limited online access and require special accommodation to access paper copies, please call (518) 408-1282.
Prior to finalizing the proposed Part 425 Adult Day Health Care Statutory Authority: Public Health Law, section 2803(2); Social Services Law, section 363-a (2) Heightened Scrutiny evidence packet(s), NYS DOH, Office of Aging and Long-Term Care, Bureau of Quality Assurance and Surveillance - ADHCP will consider all written and verbal comments received, amending determination(s) of compliance, and conducting further remediation activities as needed. NYS DOH, Office of Aging and Long Term Care, Bureau of Quality Assurance and Surveillance - ADHCP, in collaboration with the Department of Health HCBS Final Rule point of contact, will include a summary of the results in the next iteration of its HCBS Final Rule Statewide Transition Plan, which will then be subject to an additional a public comment period and subsequently posted here: https://www.health.ny.gov/health_care/medicaid/redesign/home_community_based_settings.htm
Please direct all questions to ADHCP.HCBS@health.ny.gov.
Written comments will be accepted by email at ADHCP.HCBS@health.ny.gov or by mail at:
- ADHCP
Bureau of Quality Assurance and Surveillance
Division of Nursing Homes and ICF/IID Surveillance
New York State Department of Health
875 Central Avenue
Albany, NY 12206 - ADHCP.HCBS@health.ny.gov
All comments must be postmarked or emailed by 30 days of the date of this notice.
