Public Notice
- Public Notice also available in Portable Document Format (PDF)
NYS DOH, Bureau of Managed Long Term Care Social Adult Day Care (SADC)
Heightened Scrutiny Evidence Packets
August 30, 2023
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. This is being done to maintain federal match funding for the HCBS SADC settings listed below that the Department has determined have overcome the institutional (i.e., non-eligible for HCBS funding) presumption by the United States Department of Health and Human Services (DHHS).
The SADC sites are contracted with Managed Long Term Care (MLTC) plans to provide social adult day care services, which are provided in non-residential settings. Members attend the SADC on days of their choosing, and participate in activities throughout the day, and not overnight. In addition to all other state and federal requirements the MLTC plans are responsible for providing oversight and monitoring to ensure compliance with the HCBS Final Rule for all SADC sites they contract with.
The Centers for Medicare and Medicaid Services (CMS) has issued Heightened Scrutiny requirements for HCBS settings presumed to have the qualities of an institution. Settings that fall into one of three categories that define qualities of an institution and are subject to a Heightened Scrutiny review by CMS are as follows:
- Prong 1: Setting is in a publicly or privately operated facility that provides inpatient institutional treatment.
- Prong 2: Setting is in a building on the grounds of, or adjacent to, a public institution.
- Prong 3: Setting has the effect of isolating individuals from the broader community.
CMS, based on evidence submitted by the State, will confirm whether a setting is not institutional and does have the qualities of home and community-based settings.
This notice further serves to open the 30-day public comment period that will close on September 30, 2023. The Heightened Scrutiny packets can be found here. The Department will receive written comments during the 30-day comment period via email: HCBSSADCSiteAssessments@health.ny.gov, please include a subject line of "Public Comment", or by mail to: ATTN: Paul Pfeiffer, OHIP DHPCO 1CP-1623, New York State Department of Health, Albany, NY 12237 For individuals with limited online access who require special accommodation to access paper copies, please call 518-474-6965.
Heightened Scrutiny Overview
In accordance with federal rules set forth by CMS, the NYS DOH, BMLTC is required to publish for public comment Evidence Packets for SADC sites that deliver HCBS that were identified as Heightened Scrutiny settings.
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. In order to identify SADC sites that were possibly subject to Heightened Scrutiny, MLTC plans were given a SADC site self-assessment survey to complete with all SADC sites within their network. Utilizing the returned SADC site self-assessments, DOH identified SADC sites where the MLTC plan and/or the SADC site self-identified as possibly being institutional in nature or had isolating characteristics. SADC sites at risk of being institutional or isolating in nature were prioritized for DOH review. Each site was then evaluated further for institutional and institution-like characteristics by MLTC plans conducting virtual on-site visits.
DOH has finished reviewing all SADC sites that appeared to be at risk of being institutional or isolating in nature and will continue ongoing monitoring and compliance for all SADC sites.
Strategies to Review Settings
DOH conducted a detailed review of the self-assessments and all supporting documentation and cross-referenced CMS guidance. This review was done to verify and validate the determinations made by the MLTC plans regarding the SADC site's compliance with the HCBS Final Rule and to ensure remediation efforts were completed in alignment with the federal deadline.
DOH's review entailed the following:
- Detailed review of SADC site self-assessments and all supporting documentation.
- Review of the SADC site characteristics via geo-mapping, as well as a customized map displaying each site in proximity to known health facilities.
- Individual member experience surveys sampled to identify possible institutional or isolating characteristics.
- Virtual on-site validation reviews of SADC sites which included a virtual walkthrough of the SADC site and review of SADC person-centered service plans (PCSPs).
Each SADC site was evaluated for compliance with HCBS requirements and designated as "Compliant", "Not Compliant", or "Needs Remediation". The evaluation was completed using guidance for each prong, as detailed above.
- Compliant: All SADC sites determined to be "Compliant" demonstrated no institutional or institution-like characteristics and are deemed compliant with the HCBS Final Rule. These sites were validated as not belonging to any of the three prongs.
- Needs Remediation: Those SADC sites deemed "Needs Remediation" were required to remediate any non-compliance before March 17, 2023. DOH and the MLTC plans followed up on these SADC sites to ensure the SADC site is in compliance with the HCBS Final Rule.
- Not Compliant: Based on the evaluations, this determination was made if DOH determined that some SADC sites are "Not Compliant" and unable to remediate all institutional or institution-like characteristics. In this case, DOH notified all MLTC plans that have contracts with these SADC sites that they will need to be removed from the MLTC plan's contracted network. The MLTC plans identified members receiving services at these non-compliant SADC sites and notified members to select an alternative and compliant SADC site for continued services. Members were supported in selecting and transferring to an alternative SADC site via the MLTC plan person-centered planning process
Heightened Scrutiny Categories and Summary
Based on the SADC site specific self-assessments completed and submitted by the MLTC plans, DOH identified the SADC sites that have institutional or institutional-like characteristics due to isolation components but are working to overcome these characteristics. These sites are identified below and are being reported to CMS for Heightened Scrutiny verification.
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 the BMLTC 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. | 5 |
| Prong 2 - Settings in this category are located in a building located on the grounds of, or immediately adjacent to, a public institution. | 2 |
| Prong 3 - Settings in this category may have the effect of isolating individuals from the broader community. | 45 |
Numbered List of Settings
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 |
|---|---|---|---|
| 1 | Sunshine Adult Social Center | 3 | Noted issues requiring remediation: SADC visitor's policy does not allow members to have visitors of their choosing at any time, members do not have information about how to make a request for additional services or to make changes to their SADC PCSP, and community integration opportunities are not offered to members or documented in the PCSP. Remediation efforts for community integration activities will be concluded by 07/01/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 2 | Betweenages Adult Social Center | 1 | The documentation does not demonstrate community integration activities are available, how they are requested and supported, and are not documented in PCSPs. Documentation does not indicate how members are made aware they can make PCSP changes at any time. The menu appeared to offer alternative meal options only to those with food allergies. The visitor policy contained blanket restrictions. Some of the PCSPs reviewed did not include appropriate assessment of health/safety needs and supports that may be necessary. Language in the Individualized Service Plan (ISP) Policy is non-compliant because it indicates the PCSP process is done "in conjunction with" the member. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 3 | A Plus Adult Daycare Center | 3 | The SADC PCSP did not include: modifications offered to members, members preference in which staff provides them services, health and safety risks, and support services provided to members. Community integration documentation was also limited to on-site activities and was not documented as a choice in the SADC PCSP. Remediation efforts regarding community integration were concluded by 7/1/2024 and all other remediation efforts will be completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 4 | Tremont Social Garden | 3 | Individualized community integration activities were not documented as a choice in the PCSP, individual community integration goals and supports are not provided and the PCSP indicates assistance is needed without documenting what the support is or who is responsible for providing the assistance. Remediation efforts regarding community integration will be concluded by 7/1/2024. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 5 | Silver Town Adult Day Care Center, Inc. | 3 | The documentation provided did not reflect that community integration activities are regularly offered or supported by the SADC. The SADC did not have grab bars in the downstairs restrooms and the site elevator/lift was out of order at the time of DOH's visit. PCSPs did not include supports for identified health/safety needs to support the member. Documentation indicates the member has the right to "participate" in the PCSP process. The PCSPs reviewed do not indicate how dignity and privacy are maintained when a member requests assistance with personal health matters (i.e., from a specific staff member, by gender preference). Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 6 | Good Fortune Adult Day Care Center, LLC | 3 | Community integration activities are not offered following the COVID 19 pandemic. Members who are deemed safe and competent are required to wait for staff to accompany them out of the SADC site. Additionally, the SADC PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 7 | W Day Care | 3 | Community integration activities are not offered or documented as a choice in the PCSP. Each PCSP identifies possible health/safety needs but do not address possible supports in place, referrals needed, and/or ongoing monitoring to support community integration. Language in the Service Plan Policy is non-compliant because it indicates the PCSP process is done "in conjunction with" the member. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 8 | New York Memory Center dba Park Slope Geriatric Day Center | 3 | Members do not have independent access to the community, there is no community integration provided and there are no modifications section in the PCSP. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 9 | Presbyterian Residential Community | 1 | Community integration activities are not offered to members. The PCSP template reviewed does not have a section for indicating any necessary modifications. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 10 | St. Ann's Adult Day Services @ Durand | 3 | Community integration activities and supports available to members are not adequately supported in documentation and PCSPs. PCSP goals are generic, not person-centered, and some of the PCSPs reviewed did not fully support the use of a restriction or adequately address an identified need with the supports to address them. Documentation does not reflect how information about requesting alternative meal options and/or eating in a private area is conveyed to members to ensure they are made aware of the process, does not reflect that members have a choice of activities and/or how they can select an activity different from a scheduled one, and does not reflect how members with restrictions due to documented health or safety risks would be supported to enjoy the same opportunities as their peers who are able to freely move about the setting. Documentation indicates the member has the right to "participate" in the PCSP process. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 11 | Sid Jacobson JCC | 3 | Noted issues requiring remediation: community integration opportunities are not offered to members, the SADC has not changed current policies to include HCBS specific standards, members are not given meal options, members are not allowed to have visitors of their choosing whenever they want. Remediation efforts regarding community integration will be concluded by 7/1/2024 all other remediation efforts to current policies to include HCBS specific standards and update to their visitor policy were concluded by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 12 | Melody Adult Day Care Center | 3 | Community integration activities are not offered or documented as a choice in the PCSP and PCSP sample reviewed did not show member's Plan of Care was individualized. Not all supports are documented to ensure a member can attend opportunities and activities of their interest and the SADC was unable to clarify how the service setting ensures a member's behavior supports do impede on the rights of others. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. The PCSP sample reviewed did not include documentation that the member was given a choice in who they wanted to assist them in personal needs. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 13 | 1st Choice Adult Day Care, Inc. | 3 | Community integration activities are not offered or documented as a choice in the PCSP, not all supports that are offered by the SADC are documented in the PCSP. Members are unable to choose what staff provides and/or renders services to them while at the SADC site. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff "in conjunction" with the participant instead of the member leading the development of their PCSP. More than one meal option is not offered to members and members are not able to have visitors at their choosing, at any time. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 14 | Golden Elite Adult Day Care, Inc. | 3 | The PCSP sample reviewed showed no documentation of member's goals or chosen activities and the PCSP sample did show that a member's Plan of Care is individualized. The SADC site does not offer individualized activities for community integration for members attend the SADC site and activities and/or events that involve interacting with members in the community outside of the SADC site are not offered. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff "in conjunction with" the participant instead of lead by the participant in the PCSP process. Remediation efforts regarding community integration will be concluded by 7/12024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 15 | TKV Hospitality Corp dba My Home Hicksville | 3 | 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: Community integration activities were not documented as a choice in the PCSP. PCSP sample reviewed did not show that a member's Plan of Care was individualized. The SADC site does not offer individualized activities in the community that members can participate in independently and at their choosing. The SADC does not offer members activities or events that afford them the opportunity to interact with members of the community while at the service setting. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 16 | Lord of Life Adult & Child Services, Inc. | 3 | Community integration, individualized goals, activities, and supports were not documented in the PCSP, and individualized community activities are not present on calendars, sign-ins or in policies. There is no place or indication of how dignity and privacy are maintained when a member has personal health considerations. There is no documentation that the member was given a choice in who would assist them in the PCSP. Remediation efforts regarding community integration will be concluded by 7/1/2024. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 17 | Woodhaven Lifestyle Senior Center | 3 | Community integration activities are not offered or documented as a choice in the PCSP and supports provided so the member may participate and attend opportunities and activities of their choosing are not documented for all members. The SADC does not provide information directly to members to on how to request additional services or changes. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 18 | Sunshine Days, Inc. | 3 | Noted issues requiring remediation are: community integration activities are not offered to members or document given to ensure the members can attend the opportunities and activities selected, PCSP does not show individual initiative, autonomy and independence and members rights to privacy and dignity. Remediation efforts were concluded by 3/17/2023 and included adding sections in the PCSP to show individual supports needed by member. Remediation efforts regarding community integration will be concluded by 7/1/2024. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 19 | Grand Adult Daycare | 3 | Community integration activities are not offered or documented as a choice in the PCSP and does not include information on how supports will be provided so the member may participate and attend opportunities and activities of their choosing. Additionally, The SADC PCSP does not indicate the member is able to choose alternative activities if they wish. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 20 | Gentle Personal Care, Inc. | 3 | The SADC PCSP does not include any socialization goals or activities. In addition, the PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. Community integration activities are not offered or documented as a choice in the PCSP. The PCSP does not include information on supports of how the member may participate and attend opportunities and activities of their choosing. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 21 | Sunnyside Community Services | 3 | Community integration documentation was limited to on-site activities and supporting documentation regarding alternative meal options and private dining spaces is missing. The SADC PCSP shows members at the site do not receive individualized activities that promote individual growth and/or personalized supports. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. |
| 22 | The Long Island Alzheimer's and Dementia Center | 3 | 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: Based on the documentation provided the only "community integration" offered includes group outings and does not specify independent outings, therefore does not meet HCBS compliance. The information provided in the facility's Considerations and General Guidelines document contradicts the visitation protocol and individualized community activities are not present. According to the Participant Rights document, the member only has the right to "participate" in the PCSP process rather than "lead" it. The HCBS Final Rule states the process be "driven" by the member, not by the SADC. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 23 | Wartburg | 1 | The documentation does not reflect the supports available to members, what community activities are available to them, and how members can request support to participate in activities that interest them. The activity calendar does not show that alternative activities are available to members if they do not like a scheduled activity. Information about requesting care plan changes or additional services and when this information is provided to members is unclear. PCSPs use a list of pre- listed goals instead of allowing members to create their own. Policy documentation suggests restraints are acceptable in certain situations. The PCSP template did not have a section for identifying interventions to support a member who has concerns requiring additional supports and/or modifications, as well as when the intervention would be reviewed in the future to determine if it was still necessary. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 24 | Elmhurst Adult Daycare Center Corp. | 3 | The setting does not adequately document community integration opportunities offered to members or include community integration as a choice in the PCSP. The PCSP does not include information on supports of how the member may participate and attend opportunities and activities of their choosing. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. Additionally, the SADC has no indication of how dignity and privacy are maintained and lacks a section to document member needs as it relates to personal health considerations. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 25 | Seagirt Adult Daycare Center | 3 | 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: Community integration activities were not documented as a choice in the PCSP. PCSP sample reviewed did not show that a member's Plan of Care was individualized. Activity calendar posted for members does not offer community integration or individualized activities. Not all supports are documented in the PCSP sample reviewed to ensure a member can attend opportunities and activities of interest. The SADC had conflicting policies regarding visitors. The policy posted at the SADC site did not support members having visitors of their choosing at any time. Visitors were also limited to time spent with a member. The written policy submitted prior to the visit did not have any visitor restrictions. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 26 | Hong Ning Adult Daycare Services | 3 | Community integration activities were not documented as a choice in the PCSP, and members were restricted to one visitor per policy. According to the SADC's Care Plan Policy the PCSP process is done "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. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 27 | Active Day Seniors Program | 2 | Noted issues needing remediation: The SADC's PCSP did not document information to indicate that it ensures members' rights of privacy, dignity and respect, there was no evidence of HCBS policies or training, community integration opportunities are not offered to members or documented in PCSP. Remediation efforts regarding community integration will be concluded by 7/1/2024 all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 28 | Genesis Adult Day Care | 3 | Community integration activities were not documented as a choice in the PCSP and there is no information on supports of how the member may participate and attend opportunities and activities of their choosing. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. The SADC PCSP has no indication of how dignity and privacy are maintained when the member has personal health considerations. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 29 | Golden Fleece Social Adult Day Care | 3 | Community integration activities were not documented as a choice in the PCSP and does not include information on how supports will be provided so the member may participate and attend opportunities and activities of their choosing. All necessary supports were not offered or accommodated to support the freedoms for members of all abilities in the PCSP. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 30 | Dyker Senior Center, Inc. | 3 | The setting does not provide opportunities for individualized community activities based on members' needs and preferences and community integration is not included in the PCSP. The PCSP policy is non- compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. The SADC PCSP does not show community inclusion or supports that would address the member's health and safety needs within the community. Additionally, member pronouns were incorrect in the psychosocial section of the PCSP and there is no indication of how dignity and privacy are maintained when the member has personal health considerations. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were concluded by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 31 | Finest Adult Day Care Center | 3 | Community integration documentation was limited to on-site activities, and community integration was not documented as a choice in the PCSP. Missing supporting documentation of alternative meal options and private dining spaces. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 32 | AJNY Social Daycare | 3 | Noted Issues requiring remediation: Individualized community integration and community goal opportunities are not documented in the PCSP. Remediation efforts will be concluded by 7/1/2024 and include offering independent community integration to members and updating the PCSP to include a community activities section. |
| 33 | 775 Social Day Center, Inc. | 3 | Community integration activities are not offered or documented as a choice in the PCSP and PCSP sample reviewed did not show member's Plan of Care was individualized. Not all supports are documented to ensure a member can attend opportunities and activities of their interest. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant instead of being led by the participant in the PCP process. Members are required to give advanced notice before visitors can come to the SADC site and private dining space for members was not sufficient due to storage items and cluttered observed during the visit. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 34 | Lebo Care, LLC | 2 | Community integration activities are not offered or documented as a choice in the PCSP. Remediation efforts will be concluded by 7/1/2024.The MLTC plans contracted with the SADC will be providing technical assistance. |
| 35 | Happyhouse Adult Daycare Center, Inc. | 3 | Community integration documentation was limited to on-site activities only and no supporting documentation was provided regarding volunteer and/or employment opportunities available to members. Remediation efforts regarding community integration will be concluded by 7/1/2024 and the MLTC plans contracted with the SADC will be providing technical assistance. |
| 36 | Royal Community Care Center | 3 | The availability of community integration activities and supports were not apparent in the documentation and PCSPs provided. Documentation did not make clear that alternative activities are available to members throughout the day and what the process is for requesting them. Documentation indicates the member has the right to "participate" in the PCSP process and that a PCSP is developed "in conjunction with" the member. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 37 | Borough Adult Day Care, Inc. | 3 | Noted issues requiring remediation: Individualized community Integration activities were not listed on the members' PCSP reviewed. PCSP also did not note what supports are given to members and members rights to privacy and dignity are violated. Remediation efforts regarding community integration will be completed by 7/1/2024. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 38 | Tian Nian Adult Daycare Center | 3 | Community integration documentation was limited to on-site activities, and community integration was not documented as a choice in the PCSP. The SADC was missing supporting documentation for alternative meal options and private dining spaces. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 39 | Doral Social Adult Day Care | 1 | Community integration activities were not documented as a choice in the PCSP, and the community integration activities were limited. The SADC did not include supporting documentation for independent community integration opportunities. Remediation efforts regarding community integration will be concluded by 7/1/2024 and the MLTC plans contracted with the SADC will be providing technical assistance. |
| 40 | Harmony Social Daycare Center | 3 | Community integration activities are not offered or documented as a choice in the PCSP and the PCSP sample reviewed did not show a member's Plan of Care was individualized. The PCSP policy is non- compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process. The member Bill of Rights document contains the word 'unnecessary' which implies there are circumstances where restrictions are enforced. The PCSP sample reviewed did not include documentation that the member was given a choice in who would "assist as needed" with personal needs. The activity calendar posted at the SADC site did not offer community integration and not all supports are documented to ensure a member can attend opportunities and activities of interest. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 41 | Day Day Up Adult Day Care Center, Inc. | 3 | Community integration documentation was limited to on-site activities, and community integration was not documented as a choice in the PCSP. The SADC did not submit supporting documentation for alternative meal options and private dining spaces. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 42 | Happy Healthy Adult Daycare, Inc. | 3 | Community integration documentation was limited to on-site activities, and community integration was not documented as a choice in the SADC PCSP. Remediation efforts regarding community integration will be concluded by 7/1/2024 and the MLTC plans contracted with the SADC will be providing technical assistance. |
| 43 | Staten Island Senior Lifestyle Center | 3 | Community integration activities are not offered or documented as a choice in the PCSP, and activity and event calendars are not posted at the site in order for members to determine their daily schedule and utilize opportunities presented. Members have limited choice in individualized activities. The PCSP sample reviewed documented socialization but only at the service setting. The PCSP sample reviewed did not include and not all supports necessary to ensure a member can engage in community involvement are documented. The SADC site does not offer activities or events that allow for interaction with members in the community outside of the site and transportation information is not posted at the site for members to utilize. Members are required to give advanced notice before visitors can come to the SADC site. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 44 | Sitrin Health Care | 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 verbally confirmed the site provides community activities, volunteer and/or employment opportunities in a competitive setting but the supporting documentation showed on-site activities only. The SADC did not provide a copy of an alternative menu and/or a private dining space and the member experience survey states the SADC currently doesn't allow members to have visitors due to COVID. Also, the Service Plan policy indicates the PCSP process is done "in conjunction with" the member. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 45 | Park Ave Adult Day Care Center | 3 | Individualized community integration options are not readily available and within this policy the Community Outings Policy the information only focuses on group outings not individual outings. There are no community postings group or individualized for members to be informed. The Bill of Rights, Person Centered Planning Documents and Care Plan Policy document process is not "driven" by the member, and the process appears to be led by the SADC and cannot be. Remediation efforts regarding community integration will be concluded by 7/1/2024 all other remediations were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 46 | United Adult Day Care | 3 | Community integration activities were not documented as a choice in the PCSPs including identified issues/needs or planned supports to be independent within the community, menu does not provide information on meal alternative options and modifications were not offered or accommodated to support the freedoms for members of all abilities by reviewing completed member PCSPs. According to the Participants Rights and Responsibilities document, the member only has the right to "participate" in the PCSP process rather than "lead" it. The HCBS Final Rule states the process be "driven" by the member, not by the SADC. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 47 | Royal Care of Westchester, LLC | 3 | The PCSPs reviewed do not include community integration goals, fully assess health/safety needs, and/or include the supports that may be necessary to address them. There was no HCBS Final Rule policy in place to ensure compliance with the regulation. The PCSPs reviewed do not indicate how dignity and privacy are maintained when a member requests assistance with personal health matters (i.e., from a specific staff member, by gender preference). Documentation indicates the member has the right to "participate" in the PCSP process. Language in the Participants Rights document is non-compliant because it references "unnecessary physical or chemical restraints". Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 48 | Tree of Life Adult Day Care | 3 | The SADC site was identified as having the following isolating characteristics which require remediation: the SADC does not offer community integration activities and goals included in the PCSP template, PCSP does not indicate any necessary modifications or justifications for members to move about the facility. Remediation will include amendments to PCSPs to add community integration goals and activities, to be concluded by 7/1/2024. All other remediation efforts: add a section to the PCSP that indicates necessary modifications and justifications for members to move about the facility; were completed by 3/17/2023. |
| 49 | La Familia Adult Day Center, Inc. | 3 | Community integration activities are not offered or documented as a choice in the PCSP and PCSP sample reviewed did not show member's Plan of Care was individualized. Not all supports are documented to ensure a member can attend opportunities and activities of their interest and the SADC site does not offer activities or events for interaction with members in the community. The PCSP policy is non-compliant because it indicates the service plan is developed by the program staff in conjunction with the participant in the PCSP process and the PCSP sample reviewed did not document that the member was given a choice in who would "assist as needed" with personal needs. The SADC does not have a policy and procedure for members to request for additional services or changes to their PCSP and members are not afforded flexibility in their breaks and lunches while at the SADC site. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 50 | Tanglewood Manor, Inc. | 3 | Noted issues requiring remediation: Community integration activities are not offered or documented as a choice in the PCSP, the members' rights to privacy and dignity are not noted on the PCSP's reviewed. Remediation efforts regarding community integration - the SADC will add a section under "goals" that includes community integration activities and support provided will be concluded by 7/1/2024. The MLTC plans contracted with the SADC will be providing technical assistance. SADC will add a section under "goals" that includes the community integration activities and support provided such as transportation. |
| 51 | Lucky Adult Daycare, Inc. | 3 | The PCSPs do not have community integration activities or goals listed and supports for health and safety risks are not included nor diagnoses listed to determine what supports may be needed, the information provided in the policy and procedures manual contradicts the visitation protocol. The Member Bill of Rights document is non-compliant because "unnecessary physical or chemical restraint" may never be utilized for any reason. According to the Participant's Rights document, the member only has the right to " participate " in the PCSP process rather than "lead" it. The HCBS Final Rule states the process be "driven" by the member, not by the SADC. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
| 52 | Knesset SADC | 3 | The PCSPs provided did not include goals related to community integration, have identical goals and interventions listed, with no specification related to preferred activities, outings, and/or expected outcomes. One of the PCSPs reviewed did not adequately list supports for member to participate in the listed activities. The Bill of Rights document contains language that is non-compliant because restraints (i.e., "unnecessary restraints") may never be utilized for any reason. Language in the Service Plan Policy document is non-compliant because it indicates the PCSP process is done "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. Remediation efforts regarding community integration will be concluded by 7/1/2024 and all other remediation efforts were completed by 3/17/2023. The MLTC plans contracted with the SADC will be providing technical assistance. |
A Numbered List of Settings That Cannot Overcome the Presumption
One SADC site was found non-compliant and unable to overcome the presumption that they were an institutional setting. The site is listed below. All members were supported via the MLTC plan person-centered planning process to transfer to a new SADC within 60-days of DOH's determination being sent to the contracted MLTC plans. At this time, the SADC site below is no longer in operation.
| # | SADC Site | Prong |
|---|---|---|
| 1 | Hudson Senior Adult Day Care | 1 – Unable to Remediate |
A List of Presumptively Institutional Settings Due to Isolation
The list of presumptively institutional settings due to isolation are included in the table above, as indicated by "Prong 3".
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. DOH will use any feedback from the CMS random sample review to inform whether it is applicable to similarly situated settings and additional review is needed, and/or if remediation of settings not included in the CMS review sample is necessary.
Contact Information to Submit Public Comment
A draft of the Heightened Scrutiny evidence data packets will be available for review here.
For individuals with limited online access who require special accommodation to access paper copies, please call (518) 474-6965.
Prior to finalizing the proposed Heightened Scrutiny evidence packets, the BMLTC will consider all written and verbal comments received, amending determinations of compliance, and conducting further remediation activities as needed.
Please direct all questions to HCBSSADCSiteAssessments@health.ny.gov.
Written comments will be accepted by email at HCBSSADCSiteAssessments@health.ny.gov, please indicate "Public Comment" in the subject line, or by mail at:
ATTN: Paul PfeifferOHIP DHPCO 1CP-1623
New York State Department of Health
Albany, NY 12237
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