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Updates from DOH for ACFs and AL Providers

(May 19, 2024) LeadingAge NY meets with the Department of Health (DOH) on a regular basis. During our most recent meeting, DOH provided some updates, summarized below.

Disaster and Emergency Planning Resources

DOH has noted concerns about disaster and emergency planning in both adult care facilities (ACFs) and nursing homes. Members are reminded of resources available to ensure that your plans are comprehensive. Through grant funds, the Office of Health Emergency Preparedness (OHEP) has developed training and resources, which are available to all ACFs and nursing homes free of charge. The trainings are recorded and available on the State’s Learning Management System (LMS). The Comprehensive Emergency Management Plan (CEMP) training includes templates and useful resources. Also available on the LMS is training on the use of the NYS Evacuation of Facilities in Disasters Systems (eFINDS).

Click here to access these resources.

All ACFs Will Be Receiving Narcan

As we reported previously, DOH is working with the Office of Addiction Services and Supports (OASAS) on a project to support ACFs in serving people with substance use disorders. Related to this initiative, all ACFs will be receiving an initial supply of Narcan from OASAS. The State agencies will also be providing education and information, which will be coming soon. If you receive a supply of Narcan in advance of this education effort, you can secure it until you receive more information.

ACF Financial Report Reminder

Members are reminded that the 2022 ACF Financial Report is due soon. For ACFs using a calendar year as their fiscal year, the due date is May 31, 2024. ACFs using a fiscal year period that differs from a calendar year are required to file their report by the 15th day of the sixth calendar month following the close of their fiscal year. If this falls before May 31, 2024, then the due date is May 31, 2024. Click here for more information.

Update on Federal HCBS Settings Rule and Related Activities

As we have been reporting, the State has to come into compliance with the federal Home and Community-Based Services (HCBS) Settings Rule by July. DOH will soon be asking ACF and assisted living providers to submit documentation to provide evidence to the Centers for Medicare and Medicaid Services (CMS) that they are in compliance, and this will involve an online “Drupal survey” which will ask questions and ask providers to upload policies and procedures to demonstrate compliance.

DOH plans to conduct an educational program to review the federal rule and the survey to ensure that providers understand what is expected to be in compliance. We anticipate that webinar and survey to be available soon. In the interim, they have provided information to help you begin to prepare.

While DOH has maintained that all ACFs need to comply with the federal rule, they are taking a more nuanced approach with this survey. All ACF and assisted living providers will have to complete the survey; however, if you do not serve any Medicaid recipients, you will note that and be done with the survey. Assisted Living Program (ALP) providers and other ACFs that serve the Medicaid population must complete the survey in its entirety, including the uploading of policies and procedures. DOH has provided this list so that you can begin to compile the needed documentation.

Once the training and survey are available, DOH plans to focus first on ALPs and subsequently other ACFs that serve the Medicaid population. It is anticipated that once the survey is live, providers will have two weeks to complete. In the survey, you will be asked to upload a document that demonstrates compliance with each section. For example, you can upload one document for all of the requests in Section 1, and so on.

Click here for more background on this issue.


LeadingAge NY meets with DOH frequently. Members are encouraged to provide us with questions or issues to bring to those discussions.

Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828