DOH NEWS

State of New York
Department of Health

ALBANY, February 26, 2002 — The New York State Department of Health (the Department) completed 46 unannounced standard annual nursing home surveys in April 2001, citing 44 for deficiencies. In addition, the Department fined 11 nursing homes for violations related to the care and services provided to residents.

The federal Center for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration, requires the New York State Department of Health to conduct at least one unannounced standard survey of each nursing home no later than 15 months after the previous survey. Nursing homes found to have violations are issued a Statement of Deficiencies (SOD) by the State Health Department, citing those deficiencies identified during the survey as well as the seriousness of the findings.

In cases in which a facility is issued a SOD, the administrator of the home is required to submit a Plan of Correction (POC) to the Department. The Plan of Correction states what the facility will do to correct the individual findings, what steps will be implemented to prevent the deficient practice from affecting others, as well as their protocols to monitor the effectiveness of the plan over time to prevent reoccurrence of violations. If a facility is cited for "Significant Corrections Needed," "Substandard Quality of Care," and/or "Immediate Jeopardy" (see definitions below), the Department conducts an unannounced Revisit Survey once the facility has submitted an acceptable POC.

In April 2001, the Department determined that East Neck Nursing and Rehabilitation Center (Suffolk) and Newark Manor Nursing Home (Wayne) were in compliance. Nursing homes cited for Immediate Jeopardy by the department included Good Samaritan Lutheran Health Care Center (Albany), Bainbridge Nursing and Rehabilitation Center (Bronx), Fairport Baptist Homes (Monroe), and The Waters of Syracuse (Onondaga).

Once a SOD is issued, all facilities have the opportunity to request an informal dispute resolution (IDR) with the State Health Department. This standardized process allows nursing homes to informally review any disagreements they have regarding citations issued by the Department. Once the IDR process is complete, all findings for the latest annual standard survey are posted on the New York State Department of Health web site at www.health.state.ny.us. The DOH web site includes nursing home survey information both by facility and geographic area.

The Department surveys all 679 nursing homes in New York State to ensure that residents living in these facilities are receiving the respect, dignity, and quality of care they deserve.

Nursing home surveys are outcome-based and focus on the status of the care and services provided to residents. Through the survey process, the Department reviews issues and aspects of care that impact the lives of nursing home residents. SODs categorize deficiencies in the areas of administration, quality of care, resident rights, food service, environment, and other services such as dental, pharmacy and specialized rehabilitation.

As part of the State’s surveillance of nursing homes, the Department sends a team of trained surveyors into facilities that may include registered nurses (RN's), social workers, nutritionists, and physicians. A Department representative responsible for the sanitary conditions of the facility completes the life-safety code portion of the survey (building codes, fire safety equipment and security systems).

Deficiencies, which signify a failure to meet federal and/or state regulations, range from minor to serious (examples of serious violations include, but are not limited to: avoidable weight loss, the development of avoidable pressure sores, and the occurrence of resident abuse, mistreatment or neglect). In order to identify issues, problems or potential violations, surveyors utilize three approaches: direct observation of services provided, interviews with residents, family members, direct care staff and administrators, and review of resident medical records. Once the survey team has gathered pertinent information, they analyze the data collectively and make a determination on whether deficiencies exist and a SOD should be issued.

Survey Rating - Each facility receives a rating based on the scope and severity of deficiencies found during a survey visit. One of the following ratings is associated with each standard survey. The sequence of the ratings is ordered from the most to least favorable outcome.

• In Compliance - Facility is compliant with all requirements. No deficiencies identified during the survey.
• Substantial Compliance - Facility has very minimal deficiencies that are unlikely to cause harm to residents.
• Corrections Needed - Facility has deficiencies that have the potential to cause harm or compromise the resident’s ability to maintain or improve health status.
• Significant Corrections Needed - Facility has deficiencies that have caused actual harm or compromised the resident’s ability to maintain or improve health status.
• Substandard Quality of Care - Facility has deficiencies identified in critical care and services areas that are provided by the nursing home. In some cases, a home is cited for substandard quality of care in addition to one of the deficient categories listed (typically coinciding with Significant Corrections Needed or Immediate Jeopardy).
• Immediate Jeopardy - Facility has deficiencies that have caused or are likely to cause serious harm, injury, impairment, or death if not immediately rectified.

Each nursing home has its own policies and procedures, but all must follow state and federal regulations. Some of the important aspects that individuals should look for when choosing a nursing home include, but are not limited to, complaint procedures; the use of personal belongings and furniture; the availability of ethnic foods and/or specialty diets; room assignments; reserving a bed if transferred to a hospital; visiting hours for family and friends; emergency procedures; self-care and daily assistance; leaving the facility for short visits with family and friends; the cleanliness of the facility and access to personal funds.

Also, when choosing a nursing home that will best meet their needs, individuals should consult with their doctor and the hospital discharge planning staff in cases involving hospital discharges to assess their medical, nursing and social needs. Nursing homes are required to make available the results of the most recent survey including any Plan of Correction (POC) in a readily accessible location. For further information (i.e., the number of deficiencies found at a facility) the public is recommended to go to the facility or contact its administrators for detailed information.

The following list identifies the name of the facility, its location, the highest level of deficiencies cited in April 2001, and the facilities current status. The "Current Status" is defined as the Department’s latest survey rating given to the home. Facilities listed with a current status of "Significant Corrections Needed" or "Corrections Needed" may be awaiting a Department revisit to substantiate compliance, have not yet resolved violations from the April survey or are now addressing new violations from a subsequent survey.

Both Good Samaritan Lutheran Health Care Center (Albany) and Fairport Baptist Homes (Monroe) were fined a second time in 2001 for deficiencies identified during the April standard survey noted above. Other facilities listed above may be subject to monetary penalties as well.

The State Department of Health fined the following nursing homes in April 2001 for violations related to the care and services provided to residents.

2/26/02—21 OPA