Failure to Submit CHRC 105 Form in Required Timeframe
Penalty
Summary
The facility failed to ensure that a Criminal History Record Check (CHRC) 105 Form was submitted within the required 30-day timeframe to the New York State Department of Health (NYSDOH) for an employee. This deficiency was identified during a recertification survey, where it was found that the facility received a negative determination Hold in Abeyance letter for an employee on January 8, 2025. The employee was removed from their position on the same day and did not return to work as of March 10, 2025. However, the facility did not submit the required CHRC 105 Form to the NYSDOH within the stipulated 30 days to terminate the employee from the CHRC system. The facility's policy on Criminal Background Checks, last revised in July 2023, assigned the responsibility of timely reporting of all terminations to the Human Resources Department, but did not specify a timeframe for submitting the CHRC 105 Form. During interviews, the Director of Human Resources stated that they did not submit the form because the employee had not received a Denial letter and could potentially return to work if cleared. The Administrator acknowledged that the form should have been submitted within 30 days of receiving the negative determination letter and indicated that the policy would be updated to include the timeframe for submission.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 The following actions were accomplished for the residents identified in the sample: There were no residents identified by this deficient practice. A Criminal History Record Check (CHRC) form 105 for employee #6, who received the Hold in Abeyance letter, was submitted to CHRC on 03/06/2025 which removed them from the CHRC system. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents may be affected by this deficient practice if employees who receive hold in abeyance letters are not removed from the CHRC system. On 03/27/2025 the Director of Human Resources reviewed all employees who are pending clearance for employment on the CHRC roster. There were zero (0) employees who have received a negative determination letter from CHRC requiring removal from employment at the Long Island State Veterans Home, and from the CHRC system. III. The following system changes will be implemented to assure continuing compliance with the regulations, and that the same deficient practice does not recur: The policy and procedure titled “Criminal Background Checks- Non-Licensed Personnel” was reviewed by the Interdisciplinary team (IDT). The IDT recommended that the policy be revised to contain language specifying the required time frame for employee removal from the CHRC system as per the regulations under 402.9(b)(2). Specifically, the policy was revised to state “LISVH Human Resources must immediately, but not later than 30 calendar days after the event, notify the Department when an individual is subject to CHRC via 103 submissions; and an individual is no longer subject to CHRC via 105 termination. Terminations include when an employee is no longer subject to CHRC; is no longer employed by the provider; employee death; or when a prospective employee is no longer being considered by the provider. In addition, all employees who receive a “Hold in Abeyance Letter” will be removed from the CHRC system within 30 days. In addition, the policy was revised to include a change in procedure, that no person who is offered employment at the LISVH will be permitted to commence employment without a favorable CHRC legal determination. The facility administrator, Director of Nursing and Medical Director reviewed the revised policy and approved the additional language on 03/26/2025. Beginning on 03/26/2025, the Director of Human Resources educated all Human Resources staff on the revised policy and procedure titled “Criminal Background Checks- Non-Licensed Personnel.” This education will be completed by 03/28/2025. IV. The facility’s compliance will be monitored using the following quality assurance system: Effective (MONTH) 2025, under the direction of the Quality Assurance and Performance Coordinator (QAPI) the facility developed an audit tool to ensure that employees have a favorable CHRC legal determination in their employee record prior to commencing employment. The Director of Human Resources, or authorized Human Resources staff member prior to each orientation class will review the roster of scheduled new hires to ensure that all individuals have a favorable CHRC legal determination. Individuals who do not have favorable CHRC legal determinations will not be permitted to commence employment. The compliance standard will be set to 100%. This audit will be completed for each orientation for 12 calendar months. The Human Resources staff will report audit findings during the facility’s QAPI committee meetings. At the end of the audit period the QAPI committee will review the results of the completed audits and discuss the need for further audits and at which frequency. Corrective action will be implemented as needed after the QAPI committee review of the audits. Responsibility: Director of Human Resources