Failure to Document Supervision for Employees with Pending Criminal History Checks
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements during a standard survey. Specifically, the facility did not maintain continuing documentation for the weekly supervision of two employees who were subject to the Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. Employee #6, a Certified Nurse Aide, was hired on January 26, 2024, and had a negative determination letter dated February 9, 2024. However, the only supervision documentation available was for January 31 and February 1, 2024, despite the employee working on February 11, 2024. Similarly, Employee #7, a Food Service Helper, was hired on November 7, 2023, and had a pending denial letter dated February 15, 2024. The supervision documentation for this employee was only available for select dates in November and December 2023, even though the employee worked multiple days in February 2024. Interviews with the Infection Control/In-service Coordinator, who was the Authorized Person for Criminal History Record Check, revealed that they were not involved in the Criminal History Record Check process when these employees were hired. The facility's Administrator confirmed that the only supervision documentation available for both employees were the initial Criminal History Record Check Direct Supervision Dates of Provisional Period sheets. This lack of ongoing supervision documentation for employees with pending or negative determination findings constitutes a deficiency in meeting the state's requirements.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employees found to have been missing their criminal history record check weekly supervision documentation have since been cleared for employment and no longer require weekly supervision or documentation of supervision. A review of the last three months of new hires will be completed to determine if any other employees were missing their criminal history record check weekly supervision documentation. Those identified as missing supervision will be noted, and if they continue to lack final criminal history record check clearance for employment, supervision will resume as required by state regulation. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for employee supervision when record check results are pending. A supervision sheet for each employee is created and held within the department providing supervision to the new employee. When final criminal history record check results are received, the supervision document will be marked complete and filed. Staff will be educated to ensure documentation for the weekly supervision of employees that were subject to the New York State Department of Health Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. All supervisory staff will be educated on these procedures. An audit of criminal history record check supervision documents will be completed weekly for eight weeks to assure that new employees are being supervised weekly per state regulation. 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 Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures.