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

Overall, State Health Department Data Shows That Two Out of Every Three Adult Care Facilities Are Being Cited For Violations

Albany, August 22, 2002 – State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. today released nine new reports in a series of multi–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 a result of the State multi–agency sweep, six of nine homes have been referred for enforcement action by the DOH for violations, including: Garden of Eden (Kings County), Ocean View Manor (Kings County), Bayview Manor (Kings County), Surf Manor (Kings County), Park Inn (Queens County) and Lakeside Manor (Richmond County). Other homes cited for violations were Park Manor (Kings County), Seaview Manor (Queens County) and Queens Adult Care Center (Queens County). The State is planning focused surveillance sweeps for other regions of the State. All inspections are unannounced.

In a concerted effort to better inform the public of the most recent surveillance history of adult care facilities (ACFs), Dr. Novello said that for the first time in State history, quarterly survey results are being posted on the State DOH Web site (www.health.state.ny.us). In the first six months of 2002 (January 1 through June 30), DOH data shows that two out of every three adult care facilities are being cited for violations during complaint, focused and routine surveys. The DOH inspected 320 ACFs through June 30 of this year, citing 214 for violations related to the services provided to residents and the conditions of the homes.

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. Homes cited for violations are required to take immediate steps to ensure that the problems are appropriately addressed and rectified. 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. The joint surveys are 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. Our unannounced joint surveys represent yet another example of New York's commitment to protecting adult home residents as we continue to explore options on how best to care for this vulnerable population."

In summary, the violations cited by the multi–agency surveillance teams at the nine homes collectively include 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 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."

State inspectors cited the following violations at the nine New York City homes as part of the joint–agency survey sweep:

Garden of Eden – Kings

  • Failed to report adverse incidents involving a resident death to DOH. Drug paraphernalia was found at the scene, suggesting the possibility of criminal involvement;
  • Staff did not identify those residents who failed to take their prescribed medications;
  • Staff did not consult the Medication Assistance Record when providing medication assistance;
  • The case management needs of specific residents were not being met, including incomplete documentation of their needs;
  • Resident medical evaluations were filed incomplete;
  • An elevator shaft contained considerable debris and paint thinners were improperly stored in a housekeeping room, creating a potential fire hazard; and
  • The emergency lights near a physician's office in the dining room and near a bathroom in the basement were inoperable.

Ocean View Manor – Kings

  • Failed to report adverse incidents involving seven (7) residents to DOH;
  • Failed to provide an adequate level of personal care to two residents;
  • Staff failed to maintain a place to lock–up medications for two residents;
  • There was evidence that some resident medication records were altered, staff did not follow acceptable standards of practice to document changes;
  • An emergency exit door was blocked by a vending machine;
  • Combustible items were improperly stored in the elevator room, creating a potential fire hazard;
  • Some resident bedroom windows were without curtains, blinds or shades; and
  • Numerous items in the resident bedrooms and bathrooms were dirty or required repair or replacement.

Bayview Manor – Kings

  • Failed to report adverse incidents involving three (3) residents to DOH;
  • One resident was determined to be inappropriate for remaining in the facility and was in need of a higher level of care;
  • The documentation regarding the administration of controlled substances to residents was incomplete;
  • Staff did not adequately observe residents to determine if they were ingesting their medications, nor did they thoroughly document the medications being provided;
  • The improper storage of food in the basement area created a potential for contamination;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard;
  • Electrical wiring was exposed in two separate staircase areas, creating a potential electrical hazard; and
  • Numerous items in the resident bedrooms and bathrooms were dirty or required repair or replacement.

Surf Manor – Kings

  • Failed to report adverse incidents involving five (5) residents to DOH;
  • Failed to provide an adequate level of personal care to two residents;
  • Staff failed to assist residents with medications at the appropriate times as prescribed by a physician;
  • There was no documentation that staff notified the on–site mental health services provider when a resident refuses medications;
  • There were no emergency lights in two separate staircases;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard;
  • Electrical panels and wiring were exposed in areas near resident rooms and in the elevator room, creating a potential electrical hazard;
  • There was a significant lack of clean, undamaged linen and bathroom supplies for residents; and
  • Numerous items in the resident bedrooms and bathrooms were dirty or required repair or replacement.

Park Manor – Kings

  • Failed to report adverse incidents involving four (4) residents to DOH;
  • Staff did not adequately observe residents to determine if they were ingesting their medications;
  • Resident medication records were incomplete and in some instances there were data entry errors by staff;
  • The food temperature was improperly maintained in one freezer;
  • There were no emergency lights in one of the staircases;
  • Combustible items were improperly stored in a basement storage area, creating a potential fire hazard;
  • Electrical boxes were not properly covered in several areas of the home, creating a potential electrical hazard;
  • Water temperature in two resident bathrooms exceeded the maximum allowed temperature of 110 degrees Fahrenheit;
  • Numerous items in the resident bedrooms and bathrooms were dirty or required repair or replacement; and
  • Asbestos materials were present on the coverings of several basement pipes; the coverings were broken and falling off.

Park Inn – Queens

  • Failed to ensure that adequate personal care services were available to all residents;
  • Staff did not adequately observe residents to determine if they were ingesting their medications;
  • One resident was not provided a prescribed medication as directed by the physician;
  • Documentation of the health and mental health care needs of residents was incomplete, creating a potential lapse in services for these residents;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard; and
  • Numerous items in the resident bedrooms and bathrooms were dirty and required repair or replacement.

Seaview Manor – Queens

  • Failed to ensure that adequate personal care services were available to all residents;
  • The documentation of medical and mental health evaluations was disorganized and scattered, creating a potential breakdown in the coordination of services for residents;
  • The electrical box in the elevator room was exposed, creating a potential electrical hazard;
  • There was evidence that residents were smoking cigarettes in their bedrooms and facility hallways, creating a potential fire hazard;
  • Numerous items in the resident bedrooms and bathrooms were dirty and required repair or replacement; and
  • Exhaust fans in two areas of the building were insufficient or inoperable.

Queens Adult Care Center – Queens

  • Failed to report adverse incidents involving four (4) residents to DOH;
  • Failed to properly document the operator's actions subsequent to the death of a resident;
  • There was an insufficient number of sprinkler heads in two areas of the home;
  • The emergency lighting in three areas of the home was non–existent or inoperable;
  • Combustible items were improperly stored in two areas of the home; and
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard.

Lakeside Manor – Richmond

  • Failed to report adverse incidents involving a resident to DOH;
  • The mental health evaluations for some residents were inappropriately completed by a social worker rather than by the mental health providers caring for residents, resulting in incomplete and inaccurate documentation;
  • Documentation of the case management evaluations and the needs of residents was incomplete and lacked details regarding their health and mental health care needs;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard; and
  • Numerous items in the resident bedrooms and bathrooms were dirty and required repair or replacement.

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 State Health Department to notify the State Department of Corrections (DOC), 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. The Department currently notifies the State Office of Mental Health (OMH), local Social Services districts and hospitals and nursing homes, and the State Commission on the Quality of Care for the Mentally Disabled (CQC) of this information;
  • 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;
  • Expands the reasons for which a facility is included on the "Do Not Refer"list to include citations 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;
  • Sets forth a maximum fine of $5,000 per violation. 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) assure that before discharging patients to an adult care facility the residential placement is consistent with the patient's needs.

8/22/02 – 86 OPA