Ombudsman Participation in the Department of Health Annual Survey

The New York State Department of Health is the regulatory agency responsible for investigating complaints and incidents for all long term care facilities with more than four residents.  The Department of Health conducts an annual survey of these facilities to monitor regulatory compliance, identify issues of non-compliance and approve corrective plans that will bring the facility back into compliance.

For nursing homes, the Department of Health survey is typically completed once per calendar year.  For adult homes and assisted living facilities, the cycle is typically completed once every eighteen months.

As the Ombudsman assigned to a long-term care facility you  will be asked to interact with the survey team when they are at your facility conducting their survey.  Because the survey team has a small window of time to identify areas of concern, sharing the observations and concerns you have identified with your weekly visitations is a vital part of this process.

Below are some program expectations and helpful tips for streamlining your communications with the survey team:

  • When the Department of Health enters the facility they contact HVLTCOP to give us the name of the Team Leader and their tentative date to exit (complete their inspection).  HVLTCOP then contacts the Facility Ombudsman with the name of the Team Leader, their contact information and the tentative exit date.    
  • When speaking with the Team Leader, it is important to give them the broad strokes of what you have seen at the facility including your evaluation of staff response to resident concerns.
  • It is also important for you to discuss resident concerns/complaints that don’t seem to have a permanent fix.  
  • At this time the Team Leader will alert you to the planned date and time for the exit conference and will most likely ask you to check with them on that date to confirm that they are on schedule.  The purpose of the exit conference is for the survey team to discuss their findings so that the facility can begin to develop their plan of correction.  The conference is typically attended by the Survey Team, the Administrator, Department Heads, Resident Council President and you, the Ombudsman. 

This meeting is for information only and it is not the time to make any comments unless you are invited to do so.  Your role is to note the deficiencies, the severity of them and  report issues of an emergent nature to our offices.  Don’t forget to include this on your Activity Report.