The State Health Department Cites Three Adult Care Facilities for Violations as Part of New York's Unprecedented Joint-Agency Focused Surveys

First Three Inspections Uncover Serious Violations

Albany, June 6, 2002 – State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. today released the first three reports in a series of unprecedented joint–agency focused surveys being conducted at adult care facilities (ACFs) by teams of inspectors from the State Department of Health (DOH), the State Office of Mental Health (OMH) and the Commission on the Quality of Care for the Mentally Disabled (CQC).

As part of the New York's unprecedented multi–agency sweep into adult homes, which began May 7, 2002, teams of state inspectors cited Hylan Manor Center, Inc, (Richmond County), Riverdale Manor (Bronx) and Parkview Home for Adults (Bronx) for serious violations related to the care and services provided to residents. As a result of current and past violations cited against Hylan Manor Center, Inc. by State inspectors, DOH will initiate an enforcement action against the operator, including the imposition of a $20,000 fine. The initial State surveys are unannounced and targeted 24 ACFs located in New York City. Additional unannounced surveillance sweeps are being planned for other regions of the State.

Due to the lack of compliance with State laws and regulations by some ACF operators, Governor Pataki has directed DOH, OMH and CQC to conduct joint unannounced focused surveys of adult homes with past histories of violations and in which 25 percent or more of the residents are receiving mental health services. Inspectors are particularly focusing on mental health services, the reporting of deaths and incidents involving residents, medication management, case management, room temperatures and the overall physical conditions of the homes being surveyed.

State Health Commissioner, Antonia C. Novello said, "Adult home residents have the same right to live in dignity as every New Yorker. We are holding the operators of these facilities accountable for the care and services they provided. The sweeps we are conducting with OMH and CQC will continue to ensure all adult homes provide quality living conditions."

State Office of Mental Health Commissioner James L. Stone said, "These surveys represent a crucial step forward to ensure the safety of individuals with psychiatric disabilities residing in adult homes, while making certain that they have a decent place to live as they work toward recovery."

Gary O'Brien, Chairman of the Commission on the Quality of Care for the Mentally Disabled, said, "The joint–agency surveys are an important component of New York's comprehensive adult home surveillance efforts to improve the quality of life for adult home residents. The surveys serve as an example of the collaborative efforts the three agencies are engaged in to protect adult home residents and ensure quality living conditions at the homes."

New York's surveillance actions announced today by Commissioner Novello will build on the recent legislation proposed by Governor Pataki that will prohibit referrals to ACFs, including adult homes, residences for adults and enriched housing, that do not have valid operating certificates, increase fines for violations related to care and require additional discharge planning requirements for patients released from inpatient facilities licensed or operated by the Office of Mental Health (OMH) or the Office of Alcoholism and Substance Abuse Services (OASAS).

The following are among the highlights of the Governor's recent adult home proposal:

  • The Governor's legislation would expand current law by requiring the Department, in addition to the State Office of Mental Health (OMH), local Social Services districts and hospitals, to notify nursing homes, the State Commission on the Quality of Care for the Mentally Disabled (CQC), the State Department of Corrections (DOC), the State Division of Parole (DOP), the State Office of Alcoholism and Substance Abuse Services (OASAS), the State Office of Mental Retardation and Developmental Disabilities (OMRDD) and state licensed psychiatric and rehabilitation centers of those ACFs cited for serious violations that directly affect the health, safety and welfare of residents. These agencies and health care providers would periodically receive a "Do Not Refer" list from the Department and be strictly prohibited from discharging a patient to a home designated as such.
  • Prohibits agencies and health care providers who receive a "Do Not Refer" list from directly referring a patient to any ACF required to be licensed that does not have a valid operating certificate;
  • Authorizes issuance of a "Do Not Refer" list and prohibits referrals from commonly used sources, when there are conditions found to be unsafe. This will provide DOH with a tool that can be used in serious but less egregious situations. It provides another source of information about conditions in a facility that are important to consumers, allowing them to make more informed choices. Facilities determined to be scofflaw operations by the State are included on the "Do Not Refer" list.;
  • Sets forth a maximum fine of $5,000 per violation. If a recurring violation is cited against an adult home, residence for adults or enriched housing program within a 24–month period, the maximum fine levied would increase to $10,000 per deficiency. The proposal would also remove a provision of current law that allows ACF operators to avoid State monetary penalties if they submit a written corrective action plan to DOH within 30 days of being cited for deficiencies; and
  • Requires that all State Office of Mental Retardation and Developmental Disabilities (OMRDD) developmental centers and all inpatient programs operated or licensed by OMH or the State Office of Alcoholism and Substance Abuse Services (OASAS) to assure that before discharging patients to an adult home, residence for adults or enriched housing program, that the residential placement is consistent with the patient's needs.

The joint–agency surveillance teams found violations at the three New York City homes related to inadequate medication management and documentation errors, lack of case management for some residents with histories of mental illness, the failure to report both resident deaths and adverse incidents, lack of assistance with personal care, filthy living conditions and hot water temperatures as high as 130 degrees Fahrenheit (regulations required that water temperatures in adult homes must not exceed 110 degrees Fahrenheit), among other deficiencies.

DOH has assessed a total fine of $20,000 against Hylan Manor Center, Inc. for the violations cited in May 2002 and for recurring deficiencies first identified during an August 2001 survey which cited the operator's failure to thoroughly train 12 new employees in first aid, adequately maintain resident records, file incident reports with the State, and post residents' rights and grievance procedures.

Dr. Novello also announced that for the first time in State history, quarterly adult home survey results are being made public on the State DOH Web site (www.health.state.ny.us) . In the first quarter of 2002 (January 1 through March 31), the State Health Department inspected 144 adult care facilities, citing 92 for violations related to the care and services provided to residents.

In addition, the DOH Web site now includes the "Do Not Refer" listing of adult homes that have serious violations, and these are facilities where residents should not be referred for placement.

State inspectors cited the following violations at the three New York City homes during the May 2002 joint survey sweeps;

Hylan Manor Center (Assessed a fine of $20,000)

  • Failed to report a resident's attempted suicide;
  • Did not respond appropriately to the changing health condition of a resident with diabetes. The resident was transferred to the hospital only after inspectors questioned staff about his condition;
  • Staff were not observing residents to determine if they were ingesting their medication;
  • Carts containing controlled prescriptions were not adequately supervised;
  • Two residents were allowed to remain in the same clothes several hours after bowel movements;
  • Required annual needs assessments were not completed for several residents;
  • Conditions in resident bedrooms and bathrooms were unsanitary and numerous items in many of the rooms observed required repair or replacement;
  • Staff did not routinely practice fire drills with residents;
  • Water temperature in 11 of 15 resident bathrooms exceeded the maximum allowed temperature of 110 degrees Fahrenheit; and
  • Two rooftop exhaust fans were burned out resulting in poorly vented bathrooms used by several residents.

Riverdale Manor

  • Failed to report two resident deaths (of natural causes) to DOH;
  • Failed to report adverse incidents to DOH, one incident involved a resident who sustained injuries after falling on a stairway;
  • Staff were not observing residents to determine if they were ingesting their medication;
  • Carts containing controlled prescriptions were not adequately supervised;
  • Documentation of residents' needs and the home's actions to address those needs were not completed;
  • Several residents were found to be storing expired medications in their bedrooms;
  • Food was improperly stored in refrigerators and basement areas of the home;
  • Numerous items in resident bedrooms and bathrooms were dirty or required repair or replacement; and
  • Pay phones for resident use were inoperable.

Parkview Home for Adults

  • Failed to report adverse incidents to DOH, one incident involved a resident's attempted strangulation of a nurse, while another related to a resident who was missing from the facility for more than 24 hours;
  • Water temperature in resident rooms were significantly higher than the maximum allowed temperature of 110 degrees Fahrenheit;
  • Medications ordered by residents' physicians were not listed in their charts;
  • There was no documentation that a group of residents were consuming illegal drugs and alcohol;
  • At least one other resident was determined to be inappropriate for remaining in the facility;
  • The on–site mental health provider, Bronx Psychiatric Center, was locked out of their offices by the facility operator resulting in a two–day disruption in the delivery of mental health/day treatment services to residents;
  • There was evidence that residents were allowed to smoke cigarettes in their bedrooms, creating a potential fire hazard; and
  • Ceiling tiles were dirty, worn or breaking apart in several areas throughout the home.

On average, DOH annually conducts 575 unannounced surveys of adult homes in New York State and, in addition, investigates more than 500 complaints. In 2001, DOH investigated approximately 560 complaints, resulting in 181 violations. As a result of these surveillance efforts, the Department has initiated 74 enforcement actions over the past 12 months –– more than at any other time in State history.

As part of all state inspections of ACFs, state inspectors conduct interviews, observations and record reviews to assess operational practices of the provider. The inspectors examine areas related, but not limited to, quality of care, management of residents financial accounts, resident rights, nutrition, medication practices, case management, and environmental/fire safety.

In response to State inspection reports, ACF operators have 30 days to submit corrective action plans to the appropriate State agencies noting how the home is going to correct cited violations. The State has, and will continue to, conduct unannounced re–inspections to ensure the corrections are implemented and maintained.

6/6/02 – 59 OPA