Failure to Timely Submit CHRC Termination Form
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements. Specifically, the facility did not submit the 105 Termination Form to the Criminal History Record Check (CHRC) program within thirty days after an employee, who was reassigned from direct care or supervision of residents, no longer had access to residents and their belongings. This deficiency was identified during a standard survey, affecting one of two employees reviewed for CHRC negative determination findings. The employee in question, a Certified Nurse Aide, was hired on January 26, 2024, and last worked at the facility on February 11, 2024. However, the CHRC Termination Form 105 for this employee was not submitted until October 4, 2024, well beyond the required thirty-day period. During an interview, the facility's Administrator acknowledged issues with the CHRC paperwork managed by the previous Infection Control/In-Service Coordinator, who was the authorized person for CHRC. The facility conducted audits of the paperwork but did not maintain documentation of these audits. The facility's policy, dated September 2021, mandates a CHRC for all new non-licensed employees providing care or supervision to residents and requires notification to the CHRC program within thirty days of an employee's withdrawal or termination. The failure to adhere to this policy resulted in the cited deficiency.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employee whose 105 Termination Form was not submitted to the New York State Department of Health Criminal History Record Check program within thirty days of terminations has had that termination form submitted. The facility no longer has them as an active employee in our New York State Department of Health Criminal History Record Check roster. A review of the last three months of terminations will be completed to determine if any other employees were missing their 105 Termination Form. Those identified as missing the form will be noted, and will have it submitted 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 terminating employees, via a 105 Termination Form, out of the system when they are no longer employed by the facility. Staff will be educated to ensure the 105 Termination Form will be submitted to the New York State Department of Health Criminal History Record Check (CHRC) program within thirty days of an employee being reassigned from the direct care or supervision of residents, and no longer having access to residents and their belongings. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check documents will be completed weekly for six weeks to assure that terminated employees have been removed from the New York State Department of Health Criminal History Record Check system 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.