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

Joint Surveys Continue State's Aggressive Actions to Protect Residents in Adult Homes; Two Homes Fined for Inadequate Care

Albany, July 23, 2002 – State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. today released four new reports in a series of 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 New York's unprecedented multi-agency sweep into adult homes, which began May 7, 2002, teams of state inspectors cited Anna Erika Home for Adults (Richmond), Ocean House Home for Adults (Queens), Sanford Home for Adults (Queens), and King Solomon Manor (Queens) for serious violations related to the care and services provided to residents. As part of the surveillance sweep, the inspection of Elm York Home for Adults (Queens) found the home to be in substantial compliance with State regulations.

As a result of recurring and current violations cited against Anna Erika by State inspectors, DOH has initiated an enforcement action against the operator and is seeking to collect financial penalties totaling $9,100. The Department is also seeking to collect a financial penalty of $5,100 from Ocean House for violations related to the care and services provided to residents. These adult care facilities were cited as part of the State's surveillance sweep, initially targeting 24 homes located in New York City. Additional surveillance sweeps are being planned for other regions of the State. All inspections are unannounced.

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 hygiene 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, "The adult home surveillance sweeps we are conducting with OMH and CQC will further ensure quality living conditions for residents. We will continue to work with those homes that are providing quality care and are in good standing. However, those homes found to have unsafe living conditions will be cited and required to take immediate action to address the violations. Those homes that do not comply with State regulations will face enforcement action."

State Office of Mental Health Commissioner James L. Stone said, "Our highest priority is to ensure that individuals with psychiatric disabilities residing in adult homes have every opportunity to work toward recovery in a safe, decent environment. These surveys represent a crucial step toward improving the conditions in adult care facilities for all residents."

Gary O'Brien, Chairman of the Commission on the Quality of Care for the Mentally Disabled, said, "New York's comprehensive adult home surveillance efforts are helping to improve the quality of life for residents. The unannounced joint surveys represent yet another example of New York's commitment to protecting adult home residents and ensuring quality living conditions in the homes."

The joint-agency surveillance teams found violations at four of the five New York City homes related to inadequate medication management and documentation errors, lack of case management for some residents with histories of mental illness, lack of assistance with personal care, failure to report adverse incidents involving residents and filthy living conditions.

In addition, the DOH Web site now includes quarterly adult home survey results and the "Do Not Refer" listing of adult homes that have serious violations, where residents should not be referred for placement. Facilities determined to be scofflaw operations by the State are included on the "Do Not Refer" listing.

State inspectors cited the following violations at four of the five New York City homes during the current joint-agency survey sweep:

Anna Erika Home for Adults (Assessed a fine of $9,100)

  • Staff did not adequately observe residents to determine if they were ingesting their medications;
  • Staff did not follow-up with residents who failed to take their medications as prescribed by a physician;
  • Carts containing controlled substances were not adequately supervised by staff;
  • Staff were found to be improperly returning controlled substances to the pharmacy for disposal;
  • Required annual assessments were not completed for specific residents;
  • One resident was determined to be inappropriate for remaining in the facility and was in need of a higher level of care;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard;
  • Numerous items in the resident bedrooms and bathrooms were dirty and required repair or replacement; and
  • Two rooftop exhaust fans were burned out resulting in poorly vented bathrooms shared by several residents.

Ocean House Home for Adults (Assessed a fine of $5,100)

  • The documentation of face-to-face mental health evaluations was incomplete and inaccurate for specific residents with histories of mental illness;
  • Staff did not adequately observe residents to determine if they were ingesting their medications;
  • Carts containing controlled substances were not properly secured and stored;
  • Documentation of residents' needs and the home's actions to address those needs was not completed;
  • Two residents were improperly denied access to their personal belongings by staff;
  • Residents were allowed access to an unlocked boiler room containing dangerous equipment;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard;
  • Numerous items in the resident bedrooms and bathrooms were dirty and required repair or replacement;
  • Water temperature in resident bathrooms exceeded the maximum allowed temperature of 110 degrees Fahrenheit; and
  • Food was improperly stored in refrigerators and freezers.

Sanford Home for Adults

  • Failed to report adverse incidents involving residents to DOH. The facility failed to report that one resident sustained injuries after being hit by a car and that a second resident was missing from the facility for more than 24 hours. Three other unreported incidents involved residents who suffered injuries from falls that required medical assessment and treatment;
  • Staff were not aware of medications prescribed by a physician to three residents;
  • There was inadequate documentation of the case management services provided to six residents, making it difficult to determine what services were provided and whether they were appropriate;
  • The documentation of the mental health needs of specific residents was incomplete;
  • Staff did not adequately observe residents to determine if they were ingesting their medications; and
  • An exit door leading to the roof top was fully equipped with an alarm; however the door was left unlocked, thereby providing residents access to an unsafe area of the building.

King Solomon Manor

  • There was no documentation that the mental health needs of specific residents were being met;
  • Staff did not adequately observe residents to determine if they were ingesting their medications;
  • The private psychiatrist on-site often failed to share information about residents with the case manager to ensure that appropriate mental health services were provided to them;
  • Combustible materials were found stored in an electrical panel room, creating a potential fire hazard;
  • A gas pipe in the laundry room was not properly marked and exposed asbestos was visible in the basement of the home; and
  • Water temperature in resident bathrooms exceeded the maximum allowed temperature of 110 degrees Fahrenheit.

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 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.

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 and nursing homes, to notify 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.
  • Agencies that receive the State's "Do Not Refer" list are strictly prohibited from discharging a patient to a home designated as such;
  • Agencies and health care providers who receive a "Do Not Refer" list are prohibited from directly referring a patient to any ACF required to be licensed that does not have a valid operating certificate;
  • The "Do Not Refer" list names facilities that have been cited by DOH for unsafe conditions and prohibits referrals from commonly used sources. This will provide DOH with a tool that can be used in serious but less egregious situations. The list provides consumers with another source of information about conditions in a facility, aiding them in their efforts to make informed choices;
  • A maximum fine of $5,000 per violation is established. If a recurring violation is cited against an ACF within a 24-month period, the maximum fine 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 by submitting 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 care facility that the residential placement is consistent with the patient's needs.

7/23/02-78 OPA