Reminders for ACF and AL Providers Regarding Requirements Outlined in DALs
As we come to the close of the year, we want to remind adult care facility (ACF) and assisted living members of some requirements that the Department of Health (DOH) has outlined in Dear Administrator Letters (DALs). In all cases, the Department is developing proposed regulation changes to comport with the legislation that these requirements stem from. Once those proposals are available, we will review them with members and provide comment as appropriate. In the interim, members should ensure that they are compliant with the activities outlined in the DALs.
Collection of Race and Ethnicity Data
On Oct. 14, 2022, DOH issued a DAL to ACFs announcing changes to the Chronological Admission and Discharge Register. The ACF is required to ask each newly admitted resident and those being discharged to indicate the ethnicity or race that they most closely associate with and then document the response on the DOH-5177, the Chronological Admission and Discharge Register. DOH issued an initially revised DOH-5177 and then subsequently updated the DOH-5177 again, to correct errors. Be sure to use the newest version!
Quality Assurance Committee
On March 18, 2022, DOH issued this DAL that outlines changes to law effective March 22, 2022 regarding quality assurance committees. It requires the provider to establish and incorporate quality assurance committees into each facility’s quality assurance plan to focus not only on regulatory compliance, but also on infection control. Further, each facility’s quality assurance plan must reflect a periodic meeting to take place not less than every six months to review findings identified via monitoring implementation of the facility’s plan and evaluate the effectiveness of implemented corrective action as well as trends and improvement activities. The committee must be comprised of the facility administrator and/or operator, frontline employee representatives from each area of operation, the resident council president, or other resident representative. The committee shall not consider personally identifiable resident incidents, but must meet to review and evaluate the effectiveness of each facility’s infection control plan and regulatory performance standards.
Veteran Status
On March 8, 2022, DOH issued a DAL regarding signed amendments to law that require ACFs to inquire about the veteran status of current and newly admitted residents and their spouses, and, if such resident or their spouse identifies as a veteran, to transmit veteran status information to the New York State Division of Veterans’ Services. The DAL outlines the new information that must be collected and the steps that must be taken to convey this information to appropriate parties.
Again, these are reminders of the Department’s expectations outlined in the DALs. We will keep members apprised of the regulatory promulgation process.
Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828