Adirondack Health Institute P.P.S.

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December 10, 2018

Adirondack Health Institute P.P.S.
Margaret Vosburgh, CEO
101 Ridge Street
Glens Falls, New York 12801

Dear Ms. Vosburgh:

The New York State Department of Health (Department), the Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS) are pleased to respond to the request for waivers from certain regulatory requirements submitted under the Delivery System Reform Incentive Payment (DSRIP) Program. This letter responds to the request submitted by the Adirondack Health Institute Performing Provider System (PPS).

Pursuant to Public Health Law (PHL) 2807(20) (e) and (21) (e), and in connection with DSRIP Project Plans and projects under the Capital Restructuring Financing Program that are associated with DSRIP projects, the Department, OMH, and OASAS may waive regulations for the purpose of allowing applicants to avoid duplication of requirements and to allow the efficient implementation of the proposed projects. However, the agencies may not waive regulations pertaining to patient safety nor waive regulations if such waiver would risk patient safety. Further, any waivers approved under this authority may not exceed the life of the project or such shorter time periods as the authorizing commissioner may determine.

Accordingly, any regulatory waivers approved herein are for projects and activities as described in the Project Plan application and any implementation activities reasonably associated therewith. Such regulatory waivers may no longer apply should there be any changes in the nature of a project. It is the responsibility of the PPS and the providers that have received waivers to notify the relevant agency when they become aware of any material change in the specified project that goes beyond the scope for which the waiver was granted. Further, any regulatory waivers approved are only for the duration of the projects for which they were requested.

The approval of regulatory waivers is contingent upon the satisfaction of certain conditions. In all cases, providers must be in good standing with the relevant agency or agencies. Other conditions may be applicable, as set forth in greater detail below. The failure to satisfy any such conditions may result in the withdrawal of the approval, meaning that the providers will be required to maintain compliance with the regulatory requirements at issue and could be subject to enforcement absent such compliance.

The specific request for regulatory waiver is addressed below.

1       AHI 10 NYCCR 405.19(d)(2)

Background and justification provided in your request:

Some of our most vulnerable patients in the community have long utilized the Glens Falls Hospital emergency department as their point of entry into the health care system. These vulnerable and high–risk patients continually utilize this service, often when other services or settings would be more appropriate to address their needs. It is with this understanding of the longstanding pattern in patient behavior that we strategically built a crisis stabilization unit within the ED and centered the Medical Village project around this patient "hub". The nursing staff of the Glens Falls ED are the first to engage with this population and therefore have a significant role to play in not only providing immediate care, but also engaging patients and their caregivers to be active participants in their care plan. Care plans are focused on addressing immediate needs but also include care coordination and referrals to services such as health home, SUD services and primary care which directly impacts the success of meeting DSRIP goals of reducing unnecessary inpatient admissions.

With a shortage of nurses in the ED our organization has been forced to hire temporary agency staff to meet patient demand. This approach hinders our ability to provide continuity of care as agency staff are not as familiar with the region and are not as readily able to refer patients to community–based resources which affects patient outcomes and DSRIP measures tied to project 2.a.iv. Utilizing agency staff also comes at a high cost to the organization as recruiting, onboarding and training RNs is resource intensive which only perpetuates the high cost of health care for all.

Our proposal includes a training program for our new nurses to ensure they acclimate to the fast–paced, high–stress environment of the ED with significant oversight and mentorship. By training our own nurses, as opposed to filling roles with outside agency staff, we can better manage patients to ensure they have access to the care they need with an emphasis on community–based providers within the "Medical Village". We are more likely to retain "homegrown" RNs who have been trained and mentored by leaders within our organization thus reducing turnover and further cost to the system. Our request for a waiver to NYCRR 10 Section 405.19(d)(2)(iii) carefully takes into account the intention of the regulation which is to provide quality care in an emergency setting by trained and qualified clinicians. The regulation which requires one year of experience for RNs limits the ability of our ED to address patient needs in a cost–effective and patient–centered manner due to the shortage in experienced RNs we have in our region. This in turn has a ripple effect on DSRIP P4P measures as it relates to the implementation of project 2.a.iv. By establishing a robust New Graduate Emergency Department (ED) 101 program, we can ensure RNs are supported in gaining the experience set forth in the regulation while maintaining patient safety and meeting DSRIP goals and metrics.

Response to waiver request:

ED Nurse Experience. Approved. The request to waive 10 NYCRR 405.19(d)(2) for emergency department nurses to have at least one year of clinical experience has been approved. Participants must be supervised by a preceptor during the training period. Competencies and quality data should be monitored and a year–end report provided, as outlined in the waiver application.

In cases where waivers are approved, the agencies will send letters directed to the providers which otherwise would be responsible for complying with the regulatory provisions at issue. Providers further will be advised that agency staff who conduct surveillance activities will be notified that these regulatory waivers have been approved; however, they should maintain a copy of their waiver letters at any site subject to surveillance.

Please note that the Department will continue to publish on its website a list of regulatory waivers that have been approved to assist PPSs in determining whether additional waivers may be appropriate for the activities within a PPS. Additional requests for waivers, as well as any questions regarding the foregoing, may be sent by email to with Regulatory Waiver in the subject line.

Thank you for your cooperation with this initiative. We look forward to working with you to transform New York’s delivery system.


Howard A. Zucker, M.D., J.D.
New York State Department of Health

Arlene González–Sánchez
New York State Office of Alcoholism and Substance Abuse Services

Ann Marie T. Sullivan, M.D.
New York State Office of Mental Health