NYS Health Profiles
Find and Compare New York Health Care Providers
NYS Health Profiles
Find and Compare New York Health Care Providers
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: November 3, 2022
Corrected date: N/A
Citation Details Based on interviews and record review conducted during the recertification survey from 8/9/23 to 8/15/23, the facility did not ensure that an employee who was hired on a provisional basis was provided supervision pending their criminal history record check (CHRC) completion/return for 1 of 5 employees reviewed. The findings are: Review of CHRC records of employees hired in the 4 months prior to the survey on 8/15/23 at 12:30 PM revealed: One of the five employees, specifically a facility driver, was not in compliance with supervision. The employee was not supervised from 6/1/23 to 8/15/ 23. The employee was hired on 6/1/23, but Form 103 (CHRC) was not submitted by the facility until 8/9/23, and the employee worked without documented supervision during that time, from 6/1/23 to 8/15/ 23. An undated Policy and Procedure titled Background Screening Investigations did not document a need for supervision while CHRC is pending. During an interview on 8/15/23 at 12:30 PM, the Human Resources (HR) Director stated that on (MONTH) 9th, 2023, they noticed that CHRC Form #103 had not been requested and they submitted CHRC Form # 103 on 8/9/ 23. The HR Director stated they did not have any supervision logs documented for the employee from 6/1/23 to 8/15/ 23. During an interview on 8/15/23 at 1:10 PM, the Assistant Administrator stated that they were responsible for requesting CHRC Form 103 for the employee after the previous HR Director resigned, but they did not do so. They stated they did not have any supervision logs documented for the employee from 6/1/23 to 8/15/ 23. 402. 6(d) | Plan of Correction: ApprovedNovember 30, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Fed - F - 0600 - 483. 12(a)(1) - Free from Abuse, Neglect and Exploitation Directed Plan of Correction The facility obtained the services of a consultant, not employed by the facility, to develop and implement an acceptable directed plan of correction. The Quality Assurance (QA) Committee, at a minimum, addressed the following: A. Complete an assessment of the causative factors that may have contributed to the issues identified in each of the above deficiencies. 1. RA #1 employee records were reviewed for education and training on abuse, neglect, mistreatment, and exploitation and were found to have been in compliance. CHRC records were also reviewed and found to have been in compliance with no concerning findings identified. 2. CNA #1 did not intervene to protect Resident #1 when they witnessed the alleged incident of sexual abuse by RA #1 by pulling the emergency alarm connected to the call bell, shouting or using a phone to call for help. CNA #1 reported that they were panic stricken and unable to call out for help, but had trouble speaking coherently. CNA #1 stated that they knew they should have stayed with the resident and they should have put the call light on. 3. CNA #1 failed to stay with the resident during the alleged incident of sexual abuse and ensure the resident's safety from further sexual abuse. 4. The alleged perpetrator, RA #1, was not immediately redirected to a non-resident care area and supervised after the alleged incident and staff were unaware of the whereabouts of RA #1 thereby allowing him to have access to other residents, specifically, Resident # 2. 5. Staff responding to the room to check on the wellbeing of Resident #1 failed to stay with the resident after they were notified of the alleged incident to ensure her continuing safety. 6. LPN #1 reported that in-service training did not effectively cover how to respond to an active incident of actual or threatened sexual abuse. 7. The security guard had been informed by the ADNS and DNS not to allow anyone to enter or leave the facility, however the security guard did not follow through with the directive. 8. The record of reports made to local law enforcement and the NYS Department of Health were reviewed and determined to be in compliance. 9. The facility established that policy and procedures on specifically preventing sexual abuse needed to be reviewed. 10. The facility established that staff needed to be educated on how to protect residents when an incident of actual or threatened sexual abuse has been identified. 11. The facility established that a system to ensure that staff are adequately supervised while providing care and services to residents must be implemented. B. Identify the specific steps/interventions undertaken or proposed to eliminate and correct the causative factors identified during the assessment phase. 1. The facility implemented corrective action by immediately terminating RA #1, effective 10/30/ 22. 2. The facility promptly notified local law enforcement and cooperated with law enforcement investigation. 3. The facility promptly notified the Department of Health (NYSDOH) by completing the electronic Notification of Occurrence via HCS on 10/30/ 22. 4. The facility retained the services of RN Consultant on 10/30/22, to assist with a Directed Plan of Correction and education. 5. Secure door codes were changed on 10/31/ 22. Resident #1: 1. Resident #1 was immediately transferred to the hospital emergency department for a sexual assault evaluation on 10/30/22 and returned to the facility on ,[DATE]/ 22. 2. Resident #1 returned from the hospital and received social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress. Supportive visits by social work will remain ongoing, daily, minimally x 90 days. 3. Resident #1 was evaluated by the facility psychologist on 11/1/ 22. 4. Resident #1 was evaluated by the facility psychiatrist on 11/3/ 22. 5. The room of Resident #1 was moved closer to the nurse's station on 11/1/ 22. 6. Resident # 1 was care planned for no male care on 11/1/22 and CNA accountability instructions were updated to reflect the same. 7. Victimization and trauma informed care, care plans were updated on 11/1/ 22. 8. Resident #1 has been monitored since 10/30/22 for any behavioral changes or residual effects relating to the alleged incident on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. Resident #2: 1. Resident #2 was evaluated by RNS on 11/1/ 22. Resident #2 presents with intact cognition and decision making ability and denied that she had been abused, mistreated, neglected or exploited. Resident #2 remains at her baseline. 2. Per RNS, Resident #2 declined physician, psychiatric and psychological supportive assessment as she denied victimization. 3. Social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress are being provided weekly, minimally x 90 days. 4. At risk for victimization care plan was updated by social work. 5. Resident #2 has been monitored since 11/01/22 for any behavioral changes or residual effects relating to her encounter with RA #1 following the alleged incident on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. RN Supervisor #1: 1. RNS #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. LPN #1: 1. LPN #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. CNA #1: 1. CNA #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. 2. CNA #1 was offered psychological services on 10/31/22 secondary to witnessing a traumatic event and for support with coping mechanisms to effectively manage stressful situations and emotions. CNA #2: 1. CNA #2 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. CNA #3: 1. CNA #3 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. Security Guard #1 1. Security Guard #1 was provided 1:1 individual education as developed in coordination with the RN consultant, on 11/3/ 22. The in-service education focused on the immediate need to secure the residents safety by remaining with the resident during an alleged incident, and by attempting to redirect an alleged perpetrator to a non-resident care area with supervision until police arrive. The 1:1 education also addressed the importance of following through with directives. RA #1: 1. RA #1 was immediately terminated on 10/30/ 22. 2. The police investigation of the alleged incident on 10/30/22 remains ongoing. The detective assigned to the case clarified that RA #1 has not been arrested or charged in relation to this alleged incident. 3. Facility secure door codes were changed on 10/31/22 Facility: 1. On 10/31/22, all residents residing on the two secured units (where resident #1 was allegedly sexually assaulted) were assessed by the RNS for signs/ symptoms of abuse. No evidence of abuse was identified as per RNS assessment. 2. Social worker supportive visits for all secure unit residents were provided. Emotional support remains available and ongoing to all residents. Social work will continue to monitor for late presentation of signs and symptoms of psychosocial harm. 3. On 11/2/22 the facility procedure for abuse, neglect, mistreatment, misappropriation and exploitation was reviewed during an ad hoc QAPI committee meeting in coordination with the RN Consultant. The facility's policy and procedure was amended to explicitly include that staff should remain with the resident at all times to protect the resident(s) during situations involving actual or threatened abuse and that an alleged perpetrator should be redirected to a non-resident care area and supervised until the arrival of police/ authorities. The policy also was amended to elaborate on how to identify sexual abuse, including adding additional signs and symptoms. 4. All staff have received a copy of the revised 11/02/22 policy and procedure for abuse, neglect, mistreatment, misappropriation and exploitation. 5. On 11/2/22, the RN Consultant developed an in-service lesson plan and post-test that specifically addressed the revised abuse policy and focused on sexual abuse, including signs and symptoms, and the expectation for all staff to respond appropriately by remaining with the resident at all times during an alleged incident. All facility staff were educated as per the directed in-service to redirect an alleged perpetrator to a non-resident care area to secure all residents safety, and to provide supervision of the alleged perpetrator until police/ authorities arrive. The staff demonstrated understanding by completing the post-test with a minimum score of 100%. All facility staff completed the directed in-service by 11/4/ 22. 6. Staff who were on a leave of absence will not be permitted to return to work until they receive re-education on sexual abuse and a minimum score of 100% on the post-test as per the directed lesson plan. The Director of Human Resources and Staff Development RN will be responsible to ensure that the four employees currently out on leave of absence receive the mandatory in-service prior to returning to work. 7. All employees will receive in-service training on sexual abuse response upon hire, twice per year, and as needed, and following a leave of absence. The Staff Development RN will be responsible for completion and record keeping. 8. Directed, reinforcement of sexual abuse focused in-servicing will be provided by Philosophy Care consultant on 11/29/22, 11/30/22 and on 12/1/ 22. The in-service will be mandatory for all staff. Staff members who do not participate will not be permitted to work until they complete the in-service training. The director of Human Resources and Staff Development RN will be responsible to ensure that staff who do not participate in mandatory in-servicing are not permitted to return to work prior to receiving the sexual-abuse focused in-servicing. Staff will demonstrate understanding by achieving a score of 100% on the post-test. 9. On 11/22/22, an audit tool was created by the RN Consultant in coordination with the QAPI committee to ensure that staff demonstrate retention of sexual abuse directed in-servicing. The Staff Development RN or designee will randomly audit ten staff members per week, and question the staff members for appropriate response to a sexual abuse incident. The audit will be completed by the Staff Development RN or designee weekly x 3 months, then monthly x 3 months and then quarterly x 1 year. 10. An audit tool was developed on 11/3/22 by the RN Consultant in coordination with the QAPI committee, and initiated on 11/4/22 by the facility, to ensure adequate supervision of all staff who are providing care and services to the residents. The Director of Nursing or Assistant Director of Nursing will be responsible for ensuring audits are completed by RN Supervisors twice per shift for each unit. 11. All facility RN Supervisors received directed education regarding the requirement of twice per shift rounds on each unit and the new audit tool, by 11/4/ 22. RN Supervisors demonstrated education by achieving a score of 100% on the post test. 12. The RN Consultant will reinforce directed education of RN Supervisor requirement for twice per shift rounds on each unit, and the new audit tool on 11/29/22 from 9:00am through 5:00pm, and on 11/30/22 from 9:00am through 9:00pm and on 12/1/22 from 11:00am through 1:00am on 12/2/ 22. The in-service will be mandatory for all RN Supervisors. RN Supervisors who do not participate will not be permitted to work until they complete the in-service training. The director of Human Resources and Staff Development RN will be responsible to ensure that staff who do not participate in mandatory in-servicing are not permitted to return to work prior to receiving the sexual-abuse focused in-servicing. RN Supervisors will demonstrate understanding by achieving a score of 100% on the post-test. 13. All RN Supervisors will receive in-service training on twice per shift rounds requirements, upon hire, twice per year, and as needed, and following a leave of absence. The Staff Development RN will be responsible for completion and record keeping. C. Identify the routine triggers or parameters the facility will implement for the above deficiencies that will signal or alert all staff of an evolving problem or deficient practice situation. Indicate how this system will be carried out by the facility. 1. The Staff Development RN or designee will randomly interview ten staff members per week, and question the staff members for appropriate response to a sexual abuse incident, to ensure retention of sexual abuse centered response training. The audit will be completed by the Staff Development RN or designee weekly x 3 months, then monthly x 3 months and then quarterly x 1 year. 2. RN Supervisors are now required as of 11/3/22 to observe all units, twice per shift, to ensure that staff are performing their duties according to their roles and ensuring resident safety. An audit tool was developed to document such reviews. All facility RN Supervisors received directed education regarding the new audit tool, by 11/4/ 22. D. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. 1. An audit tool was developed on 11/3/22 by the RN Consultant in coordination with the QAPI committee, and initiated on 11/4/22 by the facility, to ensure adequate supervision of all staff who are providing care and services to the residents. The Director of Nursing or Assistant Director of Nursing will be responsible for ensuring audits are completed by RN Supervisors twice per shift for each unit. The facility will measure whether efforts are successful or unsuccessful by achieving 100% compliance with the QAPI committee's goal of 100% completion of twice per shift RN Supervisor rounds on each unit and zero future incidents of sexual abuse for a period of one year. Audit findings will be presented to the QAPI Committee by the Director of Nursing or the Assistant Director of Nursing, for evaluation and follow-up, minimally quarterly, until compliance is achieved, for a minimum period of one year. 2. An audit tool was developed by the RN Consultant in coordination with the QAPI committee to ensure that staff demonstrate retention of sexual abuse directed in-servicing. The Staff Development RN or designee will randomly audit ten staff members per week, and question the staff members for appropriate response to a sexual abuse incident. The audit will be completed by the Staff Development RN or designee weekly x 3 months, then monthly x 3 months and then quarterly x 1 year. The facility will measure whether efforts are successful or unsuccessful by achieving 100% compliance with the QAPI committee's goal of 100% of all staff members interviewed reporting that they would stay with the resident during an actual or threatened sexual assault, call for assistance, and redirect the alleged perpetrator to a non-resident care area until the arrival of law enforcement. Audit findings will be presented to the QAPI Committee by the Staff Development RN or designee for evaluation and follow-up, minimally quarterly, until compliance is achieved, for a minimum period of one year. ????ö?®????? What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #1: 1. Resident #1 was transferred to the hospital emergency department for a sexual assault evaluation on 10/30/22 and returned to the facility on ,[DATE]/ 22. 2. Resident #1 returned from the hospital and received social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress. Supportive visits by social work will remain ongoing, daily, minimally x 90 days. 3. Resident #1 was evaluated by the facility psychologist on 11/1/ 22. 4. Resident #1 was evaluated by the facility psychiatrist on 11/3/ 22. 5. The room of Resident #1 was moved closer to the nurse's station on 11/1/ 22. 6. Resident # 1 was care planned for no male care on 11/1/22 and CNA accountability instructions were updated to reflect the same. 7. Victimization and trauma informed care, care plans were updated on 11/1/ 22. 8. Resident #1 has been monitored since 10/30/22 for any behavioral changes or residual effects relating to the alleged incident on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. Resident #2: 1. Resident #2 was evaluated by RNS on 11/1/ 22. Resident #2 presents with intact cognition and decision making ability and denied that she had been abused, mistreated, neglected or exploited. Resident #2 remains at her baseline. RNS reported that Resident #2 declined physician, psychiatric or psychological supportive assessment as she denied victimization. 2. Social worker supportive visits for emotional support and for monitoring for late signs of psychosocial distress. Supportive visits by social work will remain ongoing, weekly, minimally x 90 days. 3. At risk for victimization care plan was updated by social work. 4. Resident #2 has been monitored since 11/01/22 for any behavioral changes or residual effects relating to her encounter with RA #1 following the alleged on 10/30/ 22. Monitoring remains ongoing, minimally x 90 days. ????ö?®????? How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: 1. The facility concluded during the investigation that no other resident was harmed by the deficient practice. However, the potential existed for all residents to be negatively affected. The facility acknowledges that all residents of the facility are at risk for abuse, neglect, mistreatment, exploitation, and misappropriation secondary to the fact that residents may be considered vulnerable, and unable to protect themselves from perpetrators of crimes. 2. All residents have at risk for victimization care planning in place acknowledging increased risk for abuse. Care plans are updated quarterly, annually, with significant change and as needed. On 11/21/22 the Director of Social Work along with the RN Consultant verified that all facility residents have care planning in place for risk for victimization. ????ö?®????? What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: 1. On 11/2/22 the facility procedure for abuse, neglect, mistreatment, misappropriation and exploitation was reviewed during an ad hoc QAPI committee meeting in coordination with the RN Consultant. The facility policy and procedure was amended to explicitly include that staff should remain with the resident at all times to protect the resident(s) during situations involving actual or potential abuse. The policy was also amended to include that an alleged perpetrator should be redirected to a non-resident care area and supervised until the arrival of police/ authorities. The policy also was revised to elaborate on sexual abuse including adding additional signs and symptoms to assist with identifying sexual abuse. 2. On 11/2/22, the RN Consultant developed an in-service lesson plan and post-test that specifically addressed the revised policy and focused on sexual abuse, including signs and symptoms to assist with identification, and the expectation for all staff to respond appropriately by remaining with the resident at all times during an alleged incident. All facility staff were educated as per the directed in-service to also redirect an alleged perpetrator to a non-resident care area to secure all residents safety, and to provide supervision of the alleged perpetrator until police/ authorities arrive. All staff completed the directed in-service by 11/4/ 22. 3. Staff who were on a leave of absence will not be permitted to return to work until they receive re-education on sexual abuse and a minimum score of 100% on the post-test as per the directed lesson plan. The Director of Human Resources and Staff Development RN will be responsible to ensure that the four employees currently out on leave of absence receive the mandatory in-service prior to returning to work. 4. All staff will receive in-service training on sexual abuse response upon hire, twice per year, and as needed, and following a leave of absence. The Staff Development RN will be responsible for completion and record keeping. 5. Directed, reinforcement of sexual abuse focused in-servicing will be provided by Philosophy Care consultant on 11/29/22, 11/30/22 and on 12/1/ 22. The in-service will be mandatory for all staff. Staff members who do not participate will not be permitted to work until they complete the in-service training. The director of Human Resources and Staff Development RN will be responsible to ensure that staff who do not participate in mandatory in-servicing are not permitted to return to work prior to receiving the sexual-abuse focused in-servicing. Staff will demonstrate understanding by achieving a score of 100% on the post-test. 6. The RN Consultant in coordination with the QAPI committee developed an audit tool that will ensure staff retention of directed in-service training with focus on sexual abuse. The RN Consultant in collaboration with the QAPI committee initiated that the Staff Development RN or designee will randomly interview ten staff members per week, and question the staff members for appropriate response to a sexual abuse incident, to ensure retention of sexual abuse centered response training. The audit will be completed by the Staff Development RN or designee weekly x 3 months, then monthly x 3 months and then quarterly x 1 year. 7. An audit tool was developed on 11/3/22 by the RN Consultant in coordination with the QAPI committee, and initiated on 11/4/22 by the facility, to ensure adequate supervision of all staff who are providing care and services to the residents. The Director of Nursing or Assistant Director of Nursing will be responsible for ensuring audits are completed by RN Supervisors twice per shift for each unit. 8. All facility RN Supervisors received directed education regarding the requirement of twice per shift rounds on each unit and the new audit tool, by 11/4/ 22. RN Supervisors demonstrated understanding by achieving a score of 100% on the post test. 9. The RN Consultant will reinforce directed education of RN Supervisor requirement for twice per shift rounds on each unit, and the new audit tool on 11/29/22, 11/30/22, and 12/1/ 22. The in-service will be mandatory for all RN Supervisors. RN Supervisors who do not participate will not be permitted to work until they complete the in-service training. RN Supervisors will demonstrate understanding by achieving a score of 100% on the post test. The Director of Human Resources and Staff Development RN will be responsible to ensure that staff who do not participate in mandatory in-servicing are not permitted to return to work prior to receiving the in-servicing. RN Supervisors will demonstrate understanding by achieving a score of 100% on the post-test. 10. All RN Supervisors will receive in-service training on twice per shift rounds requirements, upon hire, twice per year, and as needed, and following a leave of absence. The Staff Development RN will be responsible for completion and record keeping. ????ö?®????? How will the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice 1. An audit tool was developed on 11/3/22 by the RN Consultant in coordination with the QAPI committee, and initiated on 11/4/22 by the facility, to ensure adequate supervision of all staff who are providing care and services to the residents and that there are no future incidents of sexual abuse. RN Supervisors are now required to complete audits on each unit, twice per shift, to ensure that there are no future incidents of sexual abuse. The Director of Nursing or Assistant Director of Nursing / Risk Manager will be responsible for ensuring audits are completed by RN Supervisors twice per shift. The facility will measure whether efforts are successful or unsuccessful by achieving 100% compliance with the QAPI committee's goal of 100% completion of twice per shift RN Supervisor rounds on each unit and zero future incidents of sexual abuse, for a period of one year. Audit findings will be presented to the QAPI Committee by the Director of Nursing or the Assistant Director of Nursing/ Risk Manager for evaluation and follow-up, minimally quarterly, until compliance is achieved, for a minimum period of one year. 2. An audit tool was created by the RN Consultant in coordination with the QAPI committee to ensure that staff demonstrate retention of sexual abuse directed in-servicing. The Staff Development RN or designee will randomly audit ten staff members per week, and question the staff members for appropriate response to a sexual abuse incident. The audit will be completed by the Staff Development RN or designee weekly x 3 months, then monthly x 3 months and then quarterly x 1 year. The facility will measure whether efforts are successful or unsuccessful by achieving 100% compliance with the QAPI committee's goal of 100% of all staff members interviewed reporting that they would stay with the resident during an actual or threatened sexual assault, call for assistance, and redirect the alleged perpetrator to a non-resident care area until the arrival of law enforcement. Audit findings will be presented to the QAPI Committee by the Staff Development RN or designee for evaluation and follow-up, minimally quarterly, until compliance is achieved, for a minimum period of one year. ????ö?®????? The date for correction will be on (MONTH) 1st, 2022. The facility Administrator will be responsible for compliance. |