Failure to Update Abuse/Neglect Reporting Policies
Penalty
Summary
The facility was found to be non-compliant with regulations regarding the administration and implementation of abuse and neglect reporting policies. The policy titled 'Abuse/Neglect - Reporting Process' had not been updated since December 2015, despite changes in regulations occurring between 2020 and 2024. The Director of Nursing and the Administrator were unaware of these updates, as they relied on notifications through a secure online system, which they missed. The outdated policy required incidents to be reported to the Nursing Supervisor and then to the State Health Department within five working days, which may not align with current regulatory requirements. Interviews revealed that the facility's Risk Management Team was responsible for investigating and ruling out abuse or neglect, but the Director of Nursing was unaware of updated reporting regulations. The Administrator admitted that the Policy and Procedure Team, which includes themselves and the Director of Nursing, should have updated the policies to remain compliant. Additionally, a member of the governing board believed that the Administrator was keeping policies up to date, highlighting a lack of oversight and accountability in ensuring compliance with state guidelines.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 Administration has updated the abuse and neglect reporting policies and procedures to reflect current regulatory language. This updated policy will be consistently implemented so that the facility is administered in a manner that enables it to use its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. Special attention will be paid to reporting time-frames to assure information is conveyed within guidelines set forth. An audit of all policies and procedures related to reporting incidents to the New York State Department of Health will be reviewed to assure they reflect the most current guidance. Administration will review state and federal guidance released within the past six months, as well as new guidance as it is released to assure any changes are implemented as directed and that additional staff are educated. The facility has hired a healthcare consultant to assist in establishing methodologies for ensuring compliance with state and federal regulations. The policy related to reporting abuse and neglect has been updated to reflect the most current guidance and to provide clear language of the procedures to be followed so they specifically align with regulations and reporting time-frames. Administrative staff will subscribe to state and federal long term care list serves, and monitor industry organization updates, like those sent by LeadingAge NY, of which the facility is a member. Administrative staff will receive in-service training on this policy and procedure to assure understanding. Audits of incidents reported to the state department of health will be completed as they occur to assure immediate compliance with reporting guidelines. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Administrator will be responsible for ongoing compliance with these corrective measures.