Suggested SADC Site Evaluation Tool Frequently Asked Questions (FAQs)

  • FAQs also available in Portable Document Format (PDF)

Managed Long-Term Care (MLTC)

October 27, 2022

Revision History
Change No. Change Description Change Date
1.0 Initial Version 10/27/2022

Table of Contents

Q1.1: Are MLTC Plans expected to use this tool if on-site visits were already completed before the release of this tool?

No. MLTC Plans that have already completed their on-site visits prior to the release of this tool do not need to complete another one using the new tool. It is intended to be used for on-site visits starting immediately and going forward with existing and newly contracted SADC sites.

Q1.2: Can information or additional fields be added to the Suggested Tool?

The Suggested SADC Site Evaluation Tool is editable, and MLTC Plans are free toADDadditional fields, questions, and tabs. It is important to note that existing questions cannot be removed, and all must remain in the tool.

Q1.3: Can the MLTC Plans add to the checklist of documents SADC sites should have (i.e., place of assembly, etc.)?

DOH encourages the MLTC Plans to check for and retain any additional documentation desired or believed to be best practice, ensuring compliance with all State and Federal standards.

Q1.4: Is there a set transition period for MLTC Plans to start using the Suggested Tool for future on-site visits? Will the Suggested Tool replace the tool previously used by the MLTC Plans?

The Suggested SADC Site Evaluation Tool is intended to be used starting immediately (September 2022) and going forward.

Q1.5: I understand this is a "suggested" tool but is it preferred by the DOH?

If a MLTC Plan chooses, the MLTC Plan may utilize an annual tool that of their choosing. However, it must incorporate all regulatory and HCBS Settings Final Rule compliance standards. It is required that all areas addressed in the Suggested Tool be addressed in alternative assessment tools being utilized.

DOH strongly suggests using this tool, if possible, as consistent formatting makes things easier on MLTC Plans, SADC sites, and DOH when information is being exchanged. However, the use of the Suggested Tool is not required.

Q1.6: Are PACE centers required to complete this assessment?

PACE plans are not required to follow through with this SADC oversight/compliance activity. However, PACE plans are welcome and encouraged to utilize the Suggested Tool to ensure

SADC site compliance with all State and Federal Standards. DOH is available to answer any questions and support the PACE plans.

Q2.1: What should MLTC Plans do with the completed Site Evaluation Tools? Will this tool need to be submitted to DOH annually?

The process for maintaining the SADC site evaluation tools and supporting materials remains unchanged with the release of the Suggested Tool. MLTC Plans should still retain the annual and pre-contracting tools utilized to assess each SADC site, along with supporting documentation, for seven years.

MLTC Plans should be prepared to furnish these records to any regulatory agency that requires them. DOH will be conducting additional focus surveys in the future and the plans must demonstrate annual reviews were completed for every contracted SADC site, any deficiencies were remediated, and supply all retained supporting documentation and tools.

Q2.2: I noticed the Suggested Tool does not include a nutrition review. Is the nutrition form still required?

MLTC Plans that regularly used a nutrition form for a particular SADC site previously may continue to complete them. At a minimum, the MLTC Plan must ensure the SADC is in compliance with the basic nutrition requirements listed in Site Requirements from Title 9 New York Codes, Rules, and Regulations (NYCRR) §6654.20, Attachment J. Additional details are supplied by the NYS Office for the Aging.

Q2.3: When MLTC Plans review SADC site member files, do they need to survey a 10% sample of the total SADC Site membership?

When surveying SADC site member files, it should be 10% of your MLTC Plan's membership that attends that SADC site.

Q2.4: Is the 10% sample size required or recommended?

The sample size of 10% is a general guideline, it is a best practice, and it is recommended by DOH to at least complete a 10% review to ensure that an appropriate sample is obtained, in order to gain an accurate picture of SADC site compliance with person-centered planning plan of care (POC) requirements, training standards, etc.

Q2.5: How would the member file review apply if a MLTC Plan does not have any current members at a particular contracted SADC site, at the time of the evaluation?

The Suggested Tool can be applied to the SADC site even though no members are currently receiving services. The member count would be "zero" at time of visit, but the goal is for new and existing sites to be 100% in compliance as members join. MLTC Plans would look at questions applicable to members and ensure the SADC site is prepared, so that when members join, the SADC site will be meeting all requirements.

Q2.6: Are MLTC Plans only required to collect the suggested documents in this tool? Are pictures required?

MLTC Plans are required to collect all supporting documentation needed to confirm and support compliance, remediation being conducted, etc. This may include pictures and will include documentation besides those listed on the tool. The documents listed on the tool to be collected will be utilized as guidance and additional supporting documents may be needed, depending on the situation at each SADC site.

Q2.7: Should SADC sites be provided with a copy of the completed Suggested Tool? Is it required of the MLTC Plans to do so?

The MLTC Plan may decide if they wish to share a copy of the completed Suggested Tool with the SADC site that the MLTC plan assessed. MLTC Plans are required to ensure the SADC site understands all requirements and standards, any areas of deficiency, and all agreed upon actions needed to remediate deficiencies.

Q3.1: Can DOH provide examples for the two response options for the "Does the setting of the SADC have institutional characteristics?" question from the HCBS Final Rule tab on the Suggested Tool?

Examples of a setting in a publicly or privately operated facility that provides inpatient institutional treatment would be hospitals, skilled nursing facilities, in-patient psychiatric/mental health, or intermediate care facilities.

Examples of a setting in a building on the grounds of, or adjacent to, a public institution would be county or city hospitals providing in-patient treatment.

Q3.2: What qualifies as a "public institution?" Would a school/church/social services agency be categorized as a "public institution?"

CMS defined "public institution" as it relates to the HCBS Settings Final Rule regulation, as "an inpatient facility that is financed and operated by a county, state, municipality, or other unit of government." Under this definition, a school, church, or social services agency would not be categorized as a "public institution".

Q3.3: Can you provide a definition of what "adjacent to" means? Is there a defined distance for how "adjacent to" should be measured?

For the purposes of HCBS Settings Final Rule, "adjacent to" means "next to or adjoining" an inpatient public institution. CMS did not provide an approximate distance or range for further defining whether a SADC's location is adjacent to a public institution.

Q3.4: What if a SADC site is located in a building and then an inpatient institutional treatment facility moves into the building or next door?

The SADC site would then be considered as the "setting is in a building on the grounds of, or adjacent to, a public institution". It is important to note that being adjacent to or on the grounds of a publicly or privately owned institution that provides inpatient services does not mean the SADC site is non-compliant. A SADC site may overcome this characteristic by ensuring they are separate and unaffiliated with the institution.

In the example above, the MLTC Plan can provide an explanation in the comments section of the Suggested Tool to confirm that there is a shared space, but the SADC site and hospital are separate and different entities with different administration, staffing plans, etc.

Q4.1: Why doesn't DOH take on licensing and review of SADC sites, or contract with an External Quality Review Organization (EQRO), rather than having dozens of MLTC Plans doing the same review?

DOH conducts this compliance activity via the MLTC Plan's contracts as the pathway for oversight of the SADC site network. The SADC sites are contracted directly with the plans and each plan is going to have different contract requirements that are verified. However, all MLTC Plans are ensuring their SADC sites meet State and Federal standards.

Q4.2: How will MLTC Plans know what to remediate when using the Suggested Tool?

All standards are required, but many of them can and do have exceptions that allow for some flexibility. For example, SADC sites should not have locked entrance doors or barriers to prevent participant movement. However, if staff are readily available to unlock doors or remove barriers, remediation would not be necessary.

Additionally, there are flags throughout the Suggested Tool that will alert users that a standard is not being met. The response cell may turn red or yellow to indicate an area of non- compliance, and the detailed comments box is available to explain if the circumstances have an exception and/or to describe the remediation plan that will be undertaken to reach compliance.

Q4.3: What happens if one MLTC Plan finds a SADC site to be in compliance and another does not?

It is expected by DOH that there could be instances of this occurring. However, it is up to the MLTC Plan to ensure the plan is confident that their contracted SADC sites are fully compliant with all State and Federal standards. If a MLTC Plan has a question on a particular situation or standard, they may utilize the resources and guidance provided by State and Federal agencies to gain clarity. If there is still a question, reach out to DOH for additional guidance and to discuss.

Q4.4: How should MLTC Plans properly document remediation done by SADC sites? Do those remediation plans and related documentation need to be submitted to DOH?

All MLTC Plans have been through the process of a Statement of Deficiency and a Corrective Action Plan, and the same elements from those should be included in remediation efforts (i.e., identification of non-compliance, supports to correct the issue, how to prevent the issue from recurring, and evidence of achieved compliance).

MLTC Plans should retain all completed Suggested SADC Site Evaluation Tools, as well as remediation plans, and results of remediation efforts (if needed) for each SADC for seven years.

MLTC Plans should be prepared to furnish these records to any regulatory agency that requires the documentation or asks for them.

Q4.5: Is there a suggested timeframe for remediation efforts to be completed after using the Suggested Tool and identifying non-compliance? If a SADC site does not comply within that timeframe, what are the ramifications?

MLTC Plans are required to work with all contracted SADC sites to ensure 100% compliance with all State and Federal standards by March 17, 2023 and annually thereafter. If a plan identifies a SADC site as non-compliant with one or more standards, the plan should be actively working with the SADC site to remediate those areas of non-compliance and should set an agreed upon and appropriate timeframe for the remediation to occur. DOH does not have a suggested timeframe for remediation efforts as the required remediation can vary greatly.

However, if remediation is not progressing, MLTC plans must outreach members receiving services at the site and offer transfer options to SADC sites that are already HCBS compliant. DOH will continue to assess HCBS SADC site compliance annually and report back to MLTC plans on compliance status.

Q5.1: Can MLTC Plans submit the Suggested SADC Site Evaluation Tool as the HCBS SADC Self-Assessment Survey?

No. MLTC Plans should not submit this tool in place of the HCBS SADC site specific Self- Assessment Survey, as this Suggested tool was developed for ongoing monitoring of compliance with all State and Federal standards. The HCBS SADC Self-Assessment tool is being utilized for the current HCBS Settings Final Rule compliance verification effort being undertaken from November 2021 through March 2023 and is separate from the annual Suggested Tool designed for MLTC plans' use.

Glossary and Acronyms
Acronym / Word Definition
DOH Department of Health (NYS)
HCBS Home and Community-Based Services
MLTC Managed Long-Term Care
NYS New York State
PNDS Provider Network Data System
SADC Social Adult Day Care