Failure to Timely Update Criminal History Record Check System
Summary
The facility failed to notify the New York State Department of Health when certain subject employees were no longer employed, as required by the Criminal History Record Check system. This deficiency was identified during a recertification survey, where it was found that four employees with Negative Determination Letters were not removed from the system within the mandated 30-day period following their Final Denial letters. Specifically, Employees #7, #8, #9, and #10 were not removed in a timely manner, with their Form 105 submissions occurring well beyond the 30-day requirement. The facility's policy on fingerprinting, dated 9/19/2019, mandates timely submission of terminations to keep records current. However, the Human Resources/Authorized Person revealed that these employees were never actually hired or started working at the facility before receiving their Final Denial letters. The facility's audit process, which is conducted quarterly, only included active employees who were terminated and did not account for prospective employees who were never hired. This oversight led to the delay in updating the Criminal History Record Check system, resulting in the cited deficiency.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Vice President of Human Resources or designee sent notification of termination to the New York State Department of Health for Employee #7, #8, #9 and #10. - Vice President of Human Resources or designee reviewed entire Criminal History and Record Check roster to ensure all termination notifications were sent to the New York State Department of Health for applicable staff. Identification of other residents having the potential to be affected was accomplished by: - No potential for resident impact identified. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Vice President of Human Resources or designee will complete in-service education with Human Resources Staff on provider notification requirements by 3/31/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Vice President of Human Resources or designee will audit 100% of the Criminal History and Background Check roster for compliance. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: - 4/20/25, Vice President of Human Resources
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.