DHDTC DAL 17-14 - New Psychiatric Residential Treatment Facilities (PRTF) Emergency Preparedness Regulations

November 24, 2017

DHDTC DAL 17-14: New Psychiatric Residential Treatment Facilities (PRTF) Emergency Preparedness Regulations

Dear Administrator:

This letter is written to advise you of existing reporting and new emergency preparedness regulations that apply to Psychiatric Residential Treatment Facilities (PRTF). The Department of Health (DOH) has subcontracted with IPRO to conduct compliance visits on behalf of the Centers of Medicare and Medicaid Services (CMS). To date, these visits have identified some areas of confusion, especially concerning the reporting of incidents that occur in PRTFs.


According to the State Operations Manual, Section 483.374, PRTFs must participate in several types of reporting:

Attestations of facility compliance

New PRTFs must provide an attestation of compliance to the DOH prior to executing a Medicaid provider agreement. In addition, if an existing PRTF experiences a change in their facility director, a new attestation of compliance needs to be completed and submitted to the DOH. In both cases, the attestation must be sent via email to https://apps.health.ny.gov/surveyd8/email-hospdtc. Please include "PRTF Attestation" in the subject line.

A copy of the attestation of facility compliance must be retained for surveyor inspection during an on-site review or upon request. The attestation should include, at a minimum:

  1. The facility name and location;
  2. Total number of facility beds;
  3. Number of Medicaid residents in the facility;
  4. Number of residents for whom the Psych Under 21 benefit is paid for by another state;
  5. A list of all states from whom the facility has ever received Medicaid payment for the provision of the Psych Under 21 benefit;
  6. A statement certifying that the facility currently meets all the requirements of Part 483, Subpart G, governing the use of restraint and seclusion;
  7. A statement that the facility will submit a new attestation of compliance if the facility director is no longer in such position;
  8. The date the attestation was signed.

Reporting of serious occurrences

Serious occurrences that occur at PRTFs are required to be reported to both the State Medicaid Agency, which is DOH, and the state-designated Protection and Advocacy system. Through a Memorandum of Understanding with the Office of Mental Health (OMH), reporting of serious occurrences to the New York State Incident Management and Reporting System (NIMRS) satisfies the requirement of reporting to the "State Medicaid Agency". Information about these same serious occurrences must also be reported to the state-designated Protection and Advocacy system, which is currently Disability Rights New York. PRTFs must send the information via e-mail to the following address: SOR@drny.org.

  1. Serious occurrences that must be reported include a resident's death, a resident's suicide attempt, and a serious injury as defined in Section 483.352 of the State Operations Manual.
  2. PRTF staff must report serious occurrences to NIMRS and to Disability Rights New York by no later than the close of business the next business day after the event. Reporting to Disability Rights New York is accomplished by e-mail (SOR@drny.org)
  3. In the case of a resident who is a minor, the PRTF must notify the resident's parent(s) or legal guardian(s) as soon as possible, and in no case later than 24 hours after the serious occurrence.
  4. PRTF staff must document in the resident's medical record reporting to NIMRS and Disability Rights New York (including the name of the person to whom the occurrence was reported). A copy of the report must be kept in the resident's record and in the PRTF's incident and accident report logs.

Reporting of deaths to CMS

  1. PRTF's must report the death of any resident to the CMS Regional Office by email at ronydsc@cms.hhs.gov or by fax at (443) 380-8902. Please indicate "PRTF report of death" in the subject line of an email or on the heading of the fax.
  2. Staff must report the death to the CMS regional office no later than the close of business the next business day after the resident's death.
  3. Once reporting has been accomplished, staff must document it in the resident's medical record.

Emergency Preparedness

On September 16, 2016, the final rule on Emergency Preparedness(EP) Requirements for Medicare and Medicaid Participating Providers and Suppliers was published (Federal Register Vol. 81, No. 180). This rule affects all 17 provider and supplier types eligible for participation in Medicare, including PRTFs. The rule became effective on November 15, 2016 and health care providers and suppliers affected by this rule have until November 15, 2017 to implement the new requirements and be in full compliance. Surveyors will begin evaluating the new requirements after November 15, 2017. Resources related to this rule can be found at the following link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html.

Administrators and staff of PRTFs must become familiar with the requirements and develop a plan to come into compliance with this requirement. The PRTF must develop an emergency preparedness program that meets all the standards specified within the condition/requirement. The emergency preparedness program must describe a facility's comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. The program must also address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). The emergency preparedness program must be reviewed annually. The following are requirements of an emergency preparedness program:

  1. Emergency plan

    Reviewed annually, the emergency plan provides the framework for the emergency preparedness program. The plan must:

    1. Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents;
    2. Has an all-hazards approach;
    3. Address patient/client population, including, but not limited to, persons at-risk; the type of services the PRTF can provide in an emergency; and continuity of operations, including delegations of authority and succession plans;
    4. Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts;
  2. Policies and procedures related to the emergency plan;
  3. Emergency communication plan;
  4. Training and testing plan for employees; and
  5. Emergency preparedness drills.

It is recommended that all PRTF review these new regulations in detail to plan and prepare for the implementation and monitoring of these new requirements. The Department will hold a webinar soon to address these topics. To access the links in this letter, a pdf version of this letter is available at the following link: https://www.health.ny.gov/professionals/hospital_administrator/letters/.

Thank you for your attention to this these important requirements. Should you have any questions, please contact the Division of Hospitals and Diagnostic and Treatment Centers at 518-402-1004.


Ruth Leslie
Division of Hospitals and Diagnostic & Treatment Centers

PRTF Resources

CMS State Operations Manual for PRTF

General PRTF and Psych Under 21 information from the CMS website

CMS Guidance Letters

Provision of Inpatient Psychiatric Services to Individuals Under the Age of 21(Psych Under 21 Benefit) in Out-of-State Psychiatric Residential Treatment Facilities (PRTFs)

Guidance Related to New State Operating Manual and Appendix N for Psychiatric Residential Treatment Facilities (PRTF)

Psychiatric Residential Treatment Facilities (PRTF) Frequently Asked Questions (FAQs)

Information on the Implementation Plans for the Emergency Preparedness Regulation

Information to Assist Providers and Suppliers in Meeting the New Training and Testing Requirements of the Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule

Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures