DAL: NH 17-05 - Adult Day Health Care Program Non-Residential Onsite Assessments

July 19, 2017

DAL: NH 17-05 - Adult Day Health Care Program Non-Residential Onsite Assessments

This letter is to inform you that the New York State Department of Health (Department) and Public Consulting Group, Inc. (PCG) will be conducting an onsite assessment of Home and Community Based non-residential settings, specifically Adult Day Health Care Programs. The assessments are one piece of New York's statewide transition plan to meet the federal Home and Community Based Setting (HCBS) requirements outlined in 42 CFR 441.301(c)(4) and 42 CFR 441.301(c)(5). The full plan can be viewed here:

PCG and the Department will use an assessment tool to work with Adult Day Health Care Programs to determine the current level of compliance with the HCBS requirements. There is a specific assessment tool for non-residential settings, which is attached to this letter. An inspection of the site will include, but may not be limited to, interviews with registrants and staff, review of clinical policy, billing, and other relevant questions. Many questions will be asked during the site visit; and if applicable, a meeting with the provider will occur. Pictures may be taken of the facility to assist the documentation of the site visit. Some of the questions will require PCG or the Department to view certain documents.

Once the onsite assessment has been completed, the Department will document the setting's existing level of compliance with the HCBS regulations. The Department will subsequently notify settings of its determination and whether a remediation plan is needed.

PCG or the Department will contact you prior to the onsite visit. Site visits will be starting in July. Failure to comply with the onsite assessment may place your site at risk for compliance with the HCBS Settings Rule, and possible termination as a HCBS provider.

The Department is committed to working with your program to ensure compliance with the HCBS Settings Rule. An informational question and answer section is included in the DAL.

Your prompt attention to this matter is greatly appreciated.


Mark L. Kissinger
Speical Advisor to the Commissioner
Office of Primary Care and Health
Systems Management

Shelly Glock
Director, Division of Nursing Homes and ICF/IID Surveillance
Center for Health Care Provider Services and Oversight

Question and Answer

Why is the Department conducting onsite assessments?

Per the HCBS Setting Rule released in January 2014, all states are required to review and analyze all settings in which HCBS are delivered, and report the results to the Centers for Medicare and Medicaid Services (CMS). New York State is conducting onsite assessments as one part of their effort to comply with the HCBS Settings Rule.

Who will be conducting these visits?

The Department and Public Consulting Group, Inc. (PCG), a nationally recognized public sector consulting firm, will be conducting the onsite assessments for all non-residential settings. A PCG Site Assessor can always be identified as they will be wearing a PCG employee badge.

As a provider, how should I prepare for these visits?

Providers are not expected to do anything outside of their normal operations to prepare for these site visits. The visits are designed to observe typical daily operations within the setting to evaluate the site's current level of compliance with the new HCBS standards. However, to make the visits as seamless as possible, providers should make a staff person who is familiar with the setting available for questions during the onsite visit time.

Will providers be notified of the results of their site visits?

Yes, providers will be made aware of the subsequent compliance determination. The Department will work with providers found non-compliant to develop a plan for remediation.

If you have any additional questions on the HCBS provider assessment activities, please feel free to email ADHCP.HCBS@health.ny.gov