Dear Nursing Home Administrator Letter: Nursing Care Quality Protection Act 10-03

April 9, 2010

DAL: DRS-NH 10-03 - Nursing Care Quality Protection Act

Dear Nursing Home Administrator,

On September 17, 2009, Governor Paterson signed the Nursing Care Quality Protection Act (Chapter 422 of the Laws of 2009) which added a new Public Health Law section 2805-t. This new law requires health care facilities licensed under Article 28 of the Public Health Law to provide information about select nursing care indicators upon request by a member of the public or any state agency responsible for licensing or accrediting the facility. Written statements containing such disclosed information shall state the source and date thereof. The effective date of the legislation is March 15, 2010.

In accordance with the law, the Department is in the process of promulgating regulations. This letter will outline the Department's expectations of nursing homes with respect to the provision of nursing quality indicator information consistent with the guidance provided in this document. The information provided herein will serve to assist providers in preparing for compliance with future regulations.

To assist consumers and others to interpret this information and facilitate meaningful comparisons of facility data, the regulations will require the use of established, standardized definitions and measurement criteria regarding the quality indicators included in the law.

The data provided to requestors should represent actual numbers aggregated for periods of time not to exceed 12 months and may not include data relative to planned or expected staffing.

The following are the selected nursing quality indicators for disclosure pursuant to section 2805-t of the Public Health Law. Under each subcategory, resource material is provided to assist you with meeting this requirement.

  • Percentage of high-risk and low-risk residents who have pressure ulcers.
    • Technical specifications for the complete set of Quality Measures are located: http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf
    • Providers may consider satisfying this request using specific indicator information contained on the Facility Quality Measure/Indicator Report. Please note that the facility Quality Measure/Indicator report is not publically accessible and may require data calculations in order for providers to use this information to satisfy reporting requirements.
  • Percentage of residents with urinary tract infection.
    • Technical specifications for the complete set of Quality Measures are located: http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/NHQIQMUsersManual.pdf
    • Providers may consider satisfying this request using specific indicator information contained on the Facility Quality Measure/Indicator Report. Please note that the facility Quality Measure/Indicator report is not publically accessible and may require data calculations in order for providers to use this information to satisfy reporting requirements.
  • Incidence of new fractures.
    • Providers may consider satisfying this request using specific indicator information contained on the Facility Quality Measure/Indicator Report. Please note that the facility Quality Measure/Indicator report is not publically accessible and may require data calculations in order for providers to use this information to satisfy reporting requirements.
  • Complaints and survey outcomes resulting in findings/citations.
    • This information is reported on the facility's Statement of Deficiencies (CMS Form CMS-2567), which should be made available to the requestor.
    • In accordance with 10 NYCRR 415.3 (c)(v), each resident shall have the right to: examine the results of the most recent survey of the facility conducted by federal or State surveyors including any statement of deficiencies, any plan of correction in effect with respect to the facility and any enforcement actions taken by the Department of Health. The results shall also be made available by the facility for examination. They shall be made available in a place readily accessible to residents and designated representatives without staff assistance.
    • Providers may obtain copies of requested statement of deficiencies by visiting the Department's website at http://NursingHomes.nyhealth.gov/.
    • Please note that medication error rates as described in Federal regulation 483.25(m) (1) (2) are also reported on the Statement of Deficiencies (CMS Form 2567).

The following are the selected staffing indicators that should be disclosed upon request as identified in Public Health Law section 2805-t. Providers utilizing per diem and agency staff should also include those individuals in the staffing calculations below.

  • Number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and unlicensed personnel utilized to provide direct resident care per facility, per unit and per shift.
    • Direct care means that an individual has responsibility for the residents' total care or some aspect of the residents' care.
    • Providers shall disclose actual numbers of RNs, LPNs and unlicensed personnel such as CNAs and Paid Feeding Assistants providing direct care per facility, per unit.
  • The percentage of individuals providing direct resident care (as defined above) that are RNs, LPNs, and unlicensed personnel.
    • This information should be provided upon request for each category of direct caregiver, per facility, per unit and per shift.
    • To calculate the numerator include the actual number of RNs, LPNs and/or unlicensed personnel providing direct care per facility, per unit, per shift divided by the total number of RNs, LPNs and unlicensed personnel providing direct nursing care.
    • Providers should consider utilizing up-to-date staffing information as recorded on the mandatory staff posting. (BIPA- Benefit Improvement and Protection Act)
  • Total hours per patient day for RNs, LPNs and unlicensed personnel providing direct patient care per facility, per unit and per shift.
    • Calculation should include:
      • Numerator = total nursing hours per patient day for RNs, LPNs and/or unlicensed personnel per facility, per unit and per shift.
      • Denominator = resident census including those residents in-house and those for whom a bed is being maintained (bed-hold) on the day the nursing home is reporting that census.
  • A description of the method(s) used by the facility in determining and adjusting staffing based on acuity and case mix.
    • Providers may refer to the policy and procedures developed to "outline the steps employer takes to prevent overtime." (Labor Law section 167).
    • Providers may refer to steps taken to ensure adequate nursing coverage as outlined in the facility's Nurse Coverage Plan as defined under 12 NYCRR, Part 177.

Additional information regarding measurement of the nursing quality indicators described above can be found by visiting the official website for the Centers for Medicare and Medicaid Services (CMS) at http://www.medicare.gov/nhcompare/.

Facilities will be expected to make this information available to requestors within thirty (30) days of receipt of the request. A record of requests received and completed and the source of data used to disclose this information must be maintained by the facility and made available for Department review only in the event of a request. You are encouraged to develop and implement policies and procedures to ensure compliance with the new requirements as soon as possible.

Questions regarding the Nursing Quality Protection Act may be directed to Valerie Deetz, Deputy Director, Division of Residential Services, at (518) 408-1272.

Sincerely,

Jacqueline Pappalardi
Director
Division of Residential Services