Failure to Remove Employee After Negative CHRC Determination
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements by not immediately removing an employee from direct care or supervision of residents upon receiving a negative determination letter. Specifically, Employee #6, a Certified Nurse Aide, was hired on January 26, 2024, and a negative determination letter dated February 9, 2024, was found in their file. Despite this, the employee continued to work on February 11, 2024, indicating a lapse in the facility's protocol for handling such determinations. The deficiency occurred because the facility's Criminal History Record Check Authorized Person was only checking for updates in the morning and missed the negative determination letter for Employee #6. This oversight allowed the employee to continue working with residents, contrary to the facility's policy, which mandates immediate removal from direct care upon receiving a disapproval letter. The Administrator acknowledged this procedural gap during an interview, highlighting the failure to adhere to the established policy and procedure for Criminal History Record Checks.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employee not immediately removed for direct contact or supervision of residents upon receiving New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter (Hold in Abeyance) was removed from direct contact once the determination letter was viewed and has since been cleared to return to employment at the facility. A review of the last three months of new hires will be completed to determine if any other employees were not immediately removed for direct contact or supervision of residents upon receipt of New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter documentation. No other employees were found. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for frequently checking the criminal history check result reports to assure that any negative determination letters are acted upon immediately, without delay. Additionally, systems will be in place for alternate authorized users of the New York State Department of Health Criminal History Record Check (NYSDOH CHRC) to check for results in the absence of the primary user. Staff will be educated to ensure employees are immediately removed from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check online results will be completed weekly for eight weeks to assure that any negative determination letters are viewed and acted upon the day of receipt. 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.