Nursing Home Staffing Compliance Responses Due June 11th
(June 4, 2024) On Tues., May 28th, the Department of Health (DOH) posted nursing home staffing compliance letters covering the fourth quarter of calendar year 2022. 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. While the state COVID-19 disaster emergency was ended prior to that quarter, 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.
- 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 documentation to demonstrate that reasonable attempts were made to comply.
- 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. May 28th, the date of the letter for most providers, is Day 0, making June 11th Day 10.
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 are 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 us or contact DOH at NHSafeStaffing@health.ny.gov.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841