DOH Posts Nursing Home Staffing Compliance Letters for Q1 of 2023
(Aug. 27, 2024) On Aug. 21st, the Department of Health (DOH) posted nursing home staffing compliance letters covering the first quarter of calendar year 2023. They can be accessed by individuals assigned to the roles of Administrator, Backup Administrator, Operator, and Backup Operator on the Health Commerce System (HCS), specifically in the “Health Commerce Document Management System (HCDMS)” section.
If a facility was deemed non-compliant with any of the three State staffing requirements (1.1 hours per resident day of Registered Nurse (RN)/Licensed Practical Nurse (LPN) staff time, 2.2 hours of Certified Nurse Aide (CNA), and 3.5 hours overall) on a quarterly average basis, their non-compliance letter shows the quarterly average staffing levels that DOH calculated for the home and lists the dates of non-compliance.
Facilities deemed non-compliant should first verify whether they agree with the Department’s calculations. If a facility identifies any errors that may have been made in that quarter’s submission of Payroll-Based Journal (PBJ) data or disagrees with the DOH calculations, it should submit a redetermination request using the link provided in the non-compliance letter. This must be done online and should be accompanied by a spreadsheet detailing the correct information in the format proscribed by DOH. Members may find the PBJ staffing tool for that quarter (available here) helpful in validating the DOH calculations.
Facilities that are deemed non-compliant may request a penalty reduction by completing the online penalty reduction application, which is comprised of three schedules:
- Schedule A is for extraordinary circumstances such as natural disaster or declared state emergency. The Statewide Disaster Emergency Due to Healthcare Staffing Shortages declared by the Governor (Executive Orders 4.0-4.22) lasted from September 2021 until June 2023, meaning that it was in effect for the entire quarter.
- Schedule B focuses on reasonable attempts to comply in the face of the Commissioner’s Declaration of Acute Labor Shortages. This schedule requires a narrative outlining the steps that the facility took to ensure the health and safety of the resident population during the period of non-compliance and allows the provider to report on the efforts made to try to meet the requirements. DOH requests documentation for each intervention reported. The Commissioner’s Declaration of an Acute Labor Shortage (available here) covers the full quarter and includes RNs, LPNs, and Aides in all parts of the state.
- Schedule C is to be used if the facility was engaged in a verifiable labor dispute during the quarter.
The links to both the redetermination and penalty reduction applications are provided in the letter of non-compliance.
Providers have 10 business days from the date of the letter to submit redetermination and penalty reduction requests.
DOH held two webinars regarding the compliance and penalty mitigation process in July and November 2023. The webinar recordings and slides are posted on the DOH Minimum Staffing webpage, as is a set of Frequently Asked Questions (FAQs). While both webinars walk through the penalty reduction application process, please note that the application, specifically Schedule B, was updated and streamlined after the July event.
If you have questions or encounter any difficulties in submitting the applications, please reach out to LeadingAge NY or contact DOH at NHSafeStaffing@health.ny.gov.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841