State Health Department Cites Six Adult Care Facilities for Violations as Part of New York's Unprecedented Multi-Agency Surveillance Sweep

State Takes Enforcement Action Against 11 of 23 Homes Inspected in First Sweep

Albany, September 13, 2002 - State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H. today released the six additional reports as part of the State's unprecedented multi-agency surveillance sweeps of adult care facilities (ACFs) in New York City. To date, multi-agency joint survey teams have inspected 23 adult care facilities. The survey teams are made up of inspectors from the State Department of Health (DOH), the State Office of Mental Health (OMH) and the Commission on Quality of Care and Advocacy for Persons with Disabilities (CQC).

As a result of the State's multi-agency sweep, two of the six homes cited for violations have been referred for enforcement action by the State Health Department, including: Brooklyn Manor Home for Adults (Kings) and Wavecrest Home for Adults (Queens). Overall, the State is seeking to collect fines from 11 of the 23 homes inspected as part of the unprecedented multi-agency surveillance sweep in New York City.

Dr. Novello said, "The Governor and this administration have taken a leadership role in ensuring that the residents living in adult care facilities are receiving appropriate services and are living in a safe, clean environment. We continue to be aggressive in our actions to identify problem homes as evidenced by the fact that we have initiated enforcement actions against 11 of the 23 New York City homes inspected in this initial sweep. Sweeps are now underway in other regions of the State."

In summary, the violations cited by the multi-agency surveillance teams at the six New York City homes collectively include inadequate medication management and documentation errors, failure to report adverse incidents involving residents and filthy living conditions.

State Office of Mental Health Commissioner James L. Stone said, "We are beginning to see marked progress in our multi-agency surveillance efforts to ensure that individuals with psychiatric disabilities residing in adult homes have every opportunity to work toward recovery in a safe, decent environment. The streamlining of agency resources and the teamwork that inspectors have displayed is paving the way for better living conditions for all adult home residents."

Gary O'Brien, Chairman of the Commission on Quality of Care and Advocacy for Persons with Disabilities, said, "New York's comprehensive adult home surveillance efforts are continuing to help improve the quality of life for residents. The work of the surveillance teams goes hand in hand with the State's commitment to the adult home workgroup and its charge to develop both immediate and long-range recommendations on how best to care for this vulnerable population."

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.ny.gov). 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 six New York City homes as part of the multi-agency surveillance sweep:

Brooklyn Manor - Kings (referred for enforcement action)

  • Failed to report adverse incidents involving seven (7) residents to DOH. The cases involved one resident's attempted suicide, injuries to two residents following falls, the assault of one resident by another, an improper discharge, a missing resident and a resident who alleged that she was psychologically abused by others.
  • The mental health evaluations for several residents was incomplete;
  • Staff did not seek medical treatment for one resident who suffered injuries to the face after being struck with a cane by another resident following an altercation;
  • Failed to ensure the privacy of residents in their bedrooms;
  • The administrator violated the rights of three residents when he threatened to evict one from the home and withhold Personal Needs Allowance (PNA) funds from the other two residents in an attempt to control their aggressive behavior;
  • The facility inappropriately placed resident PNA funds with facility personal funds and operating revenue;
  • The facility's daily census form was not completed on a daily basis;
  • 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, nor did they thoroughly document the medications being provided;
  • Staff failed to ensure that resident medications were stored in a secured manner;
  • Documentation of the case management evaluations and the needs of residents was incomplete and lacked details regarding their health and mental health care needs;
  • The improper storage of food in the refrigerator created a potential for contamination;
  • Employee time cards and records denoting which employees administered medications to residents showed evidence of being altered;
  • Personal care aides were allowed to administer medications to residents prior to completing a State mandated initial core-training in personal care functions;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating a potential fire hazard;
  • Water temperature in five 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
  • The facility's evacuation and disaster plan did not include specific procedures for the emergency evacuation of a resident on the second floor who was wheelchair-bound.

Wavecrest - Queens (referred for enforcement action)

  • Discontinued controlled substance medications were improperly returned to the pharmacy where they were purchased for destruction; The home itself must destroy discarded controlled substances with prior approval from DOH;
  • The covers for two sewer drain pipes were not secure in the electrical panel room, creating a potential fire hazard;
  • There was evidence that residents were smoking cigarettes in their bedrooms, creating yet another potential fire hazard - this is a repeat deficiency from March 2002;
  • The documentation for the mental health evaluations of three residents was incomplete;
  • Staff did not verify or document that the proper dosage of a specific medication for one resident, nor did they refer to resident Medication Assistance Records when providing residents with their prescribed medication to ensure the proper dosage was administered;
  • Several residents were not provided adequate supplies of toothpaste, shampoo, deodorant and shaving cream;
  • Four resident's beds were in need of clean linen;
  • The bedroom windows in two resident rooms lacked curtains, thereby compromising their right to privacy; and
  • Several resident bedrooms and bathrooms were dirty.

New Central Manor - Queens

  • A review of controlled substance medications found that the amount of discontinued medication in the facility were higher than what was documented on the Controlled Dispensing Record (CDR) the home filed with DOH;
  • Numerous items in the resident bedrooms and bathrooms were dirty or required repair or replacement; and
  • Several resident bedroom and hallway windows were in need of repair.

New Haven Manor - Queens

  • The medical evaluation for one resident was not completed until nearly two months after the resident's initial admission to the home;
  • A review of controlled substance medications found that the amount of discontinued medications in the facility were higher than what was documented on the Controlled Dispensing Record (CDR) the home filed with DOH;
  • No plan was in place to address one resident's failure to take medications and eat meals. The resident experienced considerable weight loss over seven-month period; and
  • Several resident bathroom exhaust fans were inoperable and in need of repair.

Rockaway Manor - Queens

  • Medication carts were not adequately supervised by staff;
  • Combustible materials were inappropriately stored in the electrical panel room, creating a potential fire hazard; and
  • The thermometers to monitor the temperature of the hot water system were inoperable, making it virtually impossible to gage the temperature of water for safety reasons.

Surfside Manor - Queens

  • Staff did not adequately observe residents to determine if they were ingesting their medications, nor did they thoroughly document the medications being provided; and
  • Fire dampers located in the facility's mechanical room had been permanently blocked from closing due to the presents of piping used for an air conditioning unit. The dampers were unable to prevent potential smoke fumes from entering other parts of the building, thereby creating a safety hazard.

To ensure adult homes were providing adequate care, Governor Pataki 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.

As part of state inspections of ACFs, 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 written corrective action plans disclosing how the home plans to correct the violations. The State conducts unannounced re-inspections to ensure all corrections are implemented and maintained.

The surveillance actions announced today by Commissioner Novello build on the recent legislation proposed by Governor Pataki which would prohibit referrals to ACFs, including adult homes, residences for adults and enriched housing, that do not have valid operating certificates. The measure would increase fines for violations related to care and require additional discharge planning requirements for patients released from inpatient facilities licensed or operated by OMH or the State 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 Stat's "Do Not Refer" list are strictly prohibited from referring 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 Quality of Care and Advocacy for Persons with Disabilities (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.

9/13/02-98 OPA