Failure to Timely Submit CHRC 105 Form for Non-Hired Employee
Penalty
Summary
The facility failed to submit a Criminal History Record Check (CHRC) 105 Form within the required 30-day time frame to the New York State Department of Health (NYSDOH) after receiving a negative determination letter for a prospective employee, identified as Employee #6. The facility received a Final Denial-b Letter from the NYSDOH on January 14, 2025, indicating that Employee #6 was not eligible for hire. However, the facility did not submit the necessary 105 Form to terminate Employee #6 from the CHRC system until February 14, 2025, which exceeded the 30-day requirement. The Human Resources Coordinator explained that the oversight occurred because Employee #6 was never hired and thus was not included in the facility's payroll system, which is used to generate weekly termination reports. This led to Employee #6 being overlooked in the termination process. The Administrator acknowledged that the Human Resources Coordinator should have submitted the 105 Form within the 30-day period following the receipt of the Final Denial-b Letter, as Employee #6 was never intended to be hired.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action For Employee #6, who received a Final Denial-B letter on 1/14/2025, the facility submitted the required CHRC 105 Form on 2/14/2025. Although delayed, the employee had no contact with residents, was not entered into the payroll system, and was never employed by the facility. The potential employee affected by the deficient practice had his Form 105E processed prior to the beginning of the recertification survey. The employee record has been updated to reflect the final CHRC action and the associated submission date to NYSDOH. The Human Resources Coordinator was counseled and received additional education regarding CHRC reporting timelines and the proper handling of applicants who are denied clearance but never hired. II. Identification of other employees CHRC records were reviewed and there were no other outstanding Final Denial Letters found. III. Systemic Changes The facility policy titled State Mandated Criminal History Record Check was reviewed and found to be in compliance with the regulations. The two facility Authorized Persons have been educated as to the requirement to take the necessary action when in receipt of a Final Denial Letter, within 30 days of receipt of the letter. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled State Mandated Criminal History Check. This audit will be conducted by either of the Authorized Persons every other week. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Administrator