Member Call with DOH on the LHCSA Offsite Surveillance Pilot Project
LeadingAge New York previously reported the Department of Health was initiating a pilot to conduct offsite surveillance for some Licensed Home Care Services Agencies (LHCSAs) starting Feb. 1, 2016. On Jan. 19th LeadingAge NY, along with the Home Care Association (HCA) of New York State, held a members-only call with Rebecca Fuller-Gray, Director of the Division of Home and Community-Based Services and Department of Health (DOH) on this new pilot. Ms. Fuller-Gray covered many areas that included: why was the pilot initiated, what would be included, and lastly anticipated next steps as a result of the pilot.
Ms. Fuller-Gray stated the pilot would start on Feb. 1st and end Feb. 28th. This is non-voluntary and required for the LHCSAs that are selected. This is viewed as an official DOH survey. This pilot project was initiated as a means for the DOH to increase the number of LHCSAs surveyed. There will be only 20 LHCSAs selected in the state and each DOH region will be participating. The LHCSAs that are selected have to meet three conditions:
- Must have had a re-licensure survey conducted within the past 36 months;
- Re-licensure survey and agency must have a reasonable compliance history (meaning that the agency is substantial compliance with no enforcements); and
- Cannot be a franchise.
LeadingAge NY did ask if this pilot applied to Assisted Living Programs (ALPs) and LHCSAs. We were informed they were not excluded; though DOH didn't think they would necessarily be selected by the regional offices.
The DOH Regional Office staff will be conducting the audits to determine compliance with four targeted survey areas. If a LHCSA is selected, it will be responsible for only one of the four areas. The four areas include:
- Clinical Record Review;
- Emergency Preparedness and Health Commerce System (HCS) Review;
- Personnel Record Review; and
- Quality Assurance and Complaints Review.
If selected for an offsite surveillance, you will receive a letter from HCS and via the email address provided in your LHCSA HCS account. LHCSAs will have until 5 p.m. on the date that they were notified, to provide the information to DOH. DOH will review the material submitted and conduct a telephone exit interview. Ms. Fuller-Gray suggested that LHCSAs should now review their email contacts through HCS and as noted above HCS will be a targeted surveillance area.
LHCSAs will receive Statement of Deficiencies (SODs) reports from the DOH Regional Office. The SODs will be issued via the HCS’s Electronic Plan of Correction (EPOCs) application. Again, agencies need to update their HCS contact information to ensure that the appropriate staff receive the EPOC. If LHCSAs have questions about their HCS account, please contact John Huffaker at DOH, (518) 408-1638, questions about EPOC should be directed to Melvin McClain at, (518) 408-1638. Questions on either can be sent via email to homecare@health.ny.gov.
If no deficiencies are found LHCSAs will still receive a SOD stating that the LHCSA is in compliance.
Details provided by DOH during the conference call included:
- Clinical Record Review
If this area is targeted, the LHCSA Administrator/Director of Patient Services will have to submit via fax by 5:00 p.m. the following material: a roster of active patients that encompasses start of care, patient diagnoses, patient services and frequency, payment status (managed care, private pay, etc.), and case management information; and a roster of patients discharged during the past six months (including name, discharge date and payment status).
The DOH Regional Office will request a sample that includes (two active and one discharged patient) and provide data on: start of care; primary and secondary diagnoses; receipt of certain patient rights information; medical orders; initial and ongoing assessments; plan of care; clinical supervision; aide care plan; aide activity sheets; progress notes; and discharge summary. Providers will have a 24 hour window to submit this information to DOH Regional Office.
- Emergency Preparedness and HCS Compliance Review
If this area is targeted, LHCSAs will have to demonstrate that they have a written emergency response plan; their current patient roster; and policies and procedures for HCS. DOH advised agencies to review 10 NYCRR, 766.9(c) and 766.9(o) and a May 2005, DOH Dear Administrator Letter (DAL).
- Personnel Record Review
If this area is targeted, DOH will review compliance with 10 NYCRR 766.11. Again the LHCSA Administrator/Director of Patient Services will have to submit via fax by 5:00 p.m. the agency list of active personnel. The DOH Regional Office will request a sample size of five employees from the active list that could include health screening records and tests, criminal history record checks, and documentation of completion of required in-service training.
- Quality Assurance/ Quality Improvement (QA/QI) and Compliant Procedure Review
If this area is targeted, DOH will review compliance with 10 NYCRR 766.9. DOH Regional Office staff will request a copy of the provider’s Quality Assessment Plan, a copy of the Quality Improvement Committee meeting minutes for the past 24 months, a copy of the provider’s compliant procedures, and a copy of the provider’s compliant log for the last 12 months. If the agency provides a home health training program, DOH indicated that it will also look to confirm that there is evidence that training program has a quality monitoring component by examining effectiveness of the instructors, lesson plans, material utilized, and/or student evaluations. These are some areas that would result in strategies for improvement of the training program. DOH Regional Office staff will be looking to see if identified problems had been addressed with corrective actions. Ms. Fuller-Gray stressed DOH takes the QA/QI process most seriously.
Ms. Fuller-Gray stated after the Pilot Project is completed, DOH will evaluate its effectiveness. They will review or crosswalk the number of SODs to your history, time spent in conducting the surveillance activities, and then make a recommendation to continue the offsite surveillance process, or make changes, or discontinue the process. DOH will provide written guidance sometime in mid-spring with their findings.
Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871