Auburn Inspection & Response 2008

David A. Paterson Governor

NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE 40 NORTH PEARL STREET ALBANY, NY 12243-0001

David A. Hansell Commissioner

October 24, 2008

Ms. Barbara Cohn Executive Deputy Director NYC DHS/Family Services 33 Beaver Street, 16th Floor New York, New York 10004 Dear Ms. Cohn: A complete inspection was conducted at the Auburn Family Residence on August 5, 6, 7 & 8, 2008 and September 2 & 3, 2008. Although the majority of the items were in compliance with Part 900 of Title 18 NYCRR, several findings indicate non-compliance with these regulations. Attached is the report of that inspection. Any items of non-compliance must be corrected immediately and notification of correction must be submitted detailing the corrective action taken. Where this is impossible, a written plan must be submitted detailing the corrective actions of all outstanding findings. The plan for corrective action must be submitted to this office within 30 days of the receipt of this report. In the event that an endangering condition exists and OTDA has found that the health, safety, or welfare of the public or any individual is in imminent danger, OTDA may issue an “Order of Correction” to correct such condition immediately or within any specified period of less than 30 days. If notification of the correction to the findings are not received or the findings remain outstanding without an approved plan for correction within the time period specified, OTDA may deny or withhold reimbursement for allowable expenses as defined in Section 900.15(c) of Title 18 NYCRR. Also attached to this report is the Inspector’s Comments and Recommendations (ATTACHMENT A), General Maintenance Items (ATTACHMENT B) and the Confidential Resident and Staff Findings (ATTACHMENT C) noted during our inspection. The facility’s response to these attachments must be included in the facility’s overall response to this report. COMMENTS: On the days of the inspection, 39 residents’ children between 3 months – 5 years were residing in the facility without Part 900 child-care and none were attending child-care off-site. This was a finding last year and prior years before changing to an Adult Family shelter for a year.

"providing temporary assistance for permanent change"

- 2 If you have any questions regarding the information contained in the attached inspection report or to request an electronic copy of this report, please contact Sam Foriest via e-mail at [email protected] or call (212) 961 8234. For additional information regarding homeless shelter issues, Regulations and forms please visit our new Website at: www.otda.state.ny.us/main/bhs. Sincerely, Ruth Ann Pickering Ruth Ann Pickering Deputy Director Bureau of Housing and Shelter Services Enclosure cc:

RAP/su

Robert Skallerup, DHS-CO James Russo, DHS-CO Julia Moten, DHS-CO Franca Okeya, DHS-CO Nyasha Olliver, DHS-CO Yania Gonzalez, DHS-CO Babatunde Salau, DHS-CO Bethzaida Vazquez, Director, e-mail: [email protected]

OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE REPORT DATE: 10/24/08 REPORT OF INSPECTION Facility Name: Street Address: City:

Auburn Family Residence 39 Auburn Place Brooklyn, New York 11205

County:

Kings

INSPECTION SCOPE

INSPECTOR NAMES

INSPECTION DATES

PROGRAM:

Shirley Haines

August 5 – 8, 2008

ENVIRONMENT:

Carol Whaley

September 2 & 3, 2008

INSTRUCTIONS FOR SUBMITTING DEPARTMENT OF HOMELESS SERVICES (DHS) FAMILY SHELTER INSPECTION RESPONSES VIA E-MAIL OR HARD COPY FOR DEPARTMENT OF HOMELESS SERVICES SHELTERS ONLY • Once NYS OTDA completes a facility inspection report, a copy of the report will be e-mailed to the facility’s Program Administrator at DHS and to the facility with e-mail capability. •

A hard copy of the facility’s inspection report will also be mailed to the facility.

PART A – DHS’s Response to the Inspection Report. This section requires that the facility’s violation be completed by the approved district only. The district must collaborate with the facility prior to submitting a response. The district must be specific and state the time period when the deficiency will be corrected. PART B – Facility’s Response to the Inspection Report. This section requires that the facility respond to violations in the inspection report. The responses should be complete and include responses to the Facility’s Findings, Inspector’s Comments and Recommendations (Attachment A) and the Maintenance Deficiencies (Attachment B). The facility’s follows:

response

to

the

inspection

report

should

be

addressed

as

α) The facility’s response to the Facility’s Findings must be typed in bold in the Facility’s Response Box located below OTDA’s Corrective Action. β) The facility’s response to the Inspector’s Recommendations (Attachment A) must be typed in bold under each recommendation. χ) The facility’s response to Maintenance Deficiencies (Attachment B) must be typed in bold after each maintenance item. δ) The facility’s response to the “Confidential Resident and Staff Findings” (Attachment C) must be addressed according to the specific individual and finding as noted on the attachment. The facility’s hard copy response to the inspection report must be mailed to the Director of Quality Assurance and Support at DHS or e-mail the response to [email protected] and [email protected]. Note: All facility responses to the inspection report must be forwarded to DHS for their approval before they are forwarded to OTDA. •

After the DHS Program Administrator has reviewed and approved the facility’s response, a copy of the complete report must be sent, via emailed to: [email protected] or send a hard copy to Ruth Ann Pickering, Deputy Director, Bureau of Housing and Shelter Services, Office of Temporary and Disability Assistance, 40 North Pearl Street, 10th Floor, Section B, Albany, New York 12243.

•

OTDA will review all facility responses for compliance and, if necessary, request DHS and the facility to submit additional information.

PART A - DHS RESPONSE TO THE INSPECTION REPORT ONLY. REPORT DATE: 10/24/08 FACILITY NAME: Auburn Family Residence DISTRICT: Department of Homeless Services RESPONSE SUBMITTED BY:

DATE OF RESPONSE:

TELEPHONE:

E-MAIL ADDRESS:

TITLE:

REPORT OF INSPECTION VIOL REGULATION NUMBER 1 900.3(3)(e) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: New York City Department of Homeless Services (DHS) failed to submit to the Office of Temporary and Disability Assistance (OTDA) a request to renew the approval of the facility’s Operational Plan. The facility’s operational plan expired on 05/05/2005. (Over the previously cited years, the facility did not submit an amended Operational Plan to reflect the different populations serviced and the different programs provided.) (Previously cited 11/15/01, 12/20/02, 01/09/04, 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: DHS must submit a request to renew the approval of the facility’s Operational Plan on OTDA’s current automated Part 900 Operational Plan CD format. A copy of the OTDA Operational Plan CD was provided the director during the inspection and additional copies may be requested by contacting OTDA. DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) The operational plan for Auburn and all DHS Directly operated facilities is currently being updated and will be submitted to central office by Jan.31, 2009 for review and then forwarded to OTSA for approval. VIOL REGULATION NUMBER 2 900.10(c)(5)(i)&(ii) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to provide structured child-care services for resident children between the ages of 3 months through 5 years. On the days of the inspection, there were 39 resident children between 3 months – 5 years and none of the children were attending child-care either on or off-site. (Previously cited 03/26/07 and prior years when Auburn was a family shelter) CORRECTIVE ACTION: DHS must ensure that child-care is provided to accommodate all families who are engaged in welfare-to-work initiatives such as: employment, job training, attending an educational program, looking for housing or for short-term emergency care. DHS must assign and designate appropriate rooms for childcare as well as hiring appropriate staff.

DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) DHS is working with this provider to address your concerns regarding childcare and will submit a complete response for this item in subsequent correspondence.

VIOL REGULATION NUMBER 3 900.11(a)(3) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that adequate and appropriate electronic surveillance equipment was installed to view the grounds, facility, and activities of the residents in order to lessen the risk of resident injury, prevention of theft and unauthorized persons from entering the facility. (Previously cited 11/15/01, 12/20/02, 01/09/04, 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: DHS must ensure that the facility install an electronic security surveillance system that will cover the entrance door, perimeter of the building and lobby of first floor. The surveillance system must have recording capabilities and the system must also allow for playback while the system continues to record. If the system is not digital, storage space must be available for the tapes to be securely stored for a minimum of 14 days. DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) A proposal for the installation of CCTV Cameras was submitted to Central Office on March 2007 and was approved. Meeting with “Northern Video Systems Inc.” was held on Jan. 2008. We are currently waiting for the completion of the window and fire alarm installation in order to pursue the installation of the CCTV Monitor. The CCTV camera installation is scheduled begin in February, 2009 at all directly operated family facilites.

VIOL REGULATION NUMBER 4 900.11(b) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to have a sufficient number of staff on-site to supervise and to provide appropriate services that the facility is required to provide. The following positions are needed at the facility: a)

An additional housing specialist is needed to assist families to obtain permanent housing. The facility’s population consists of Next Step, long-term and general population families and there is only one housing specialist assigned to the facility to work with all these different groups of families. Thirty-three (33) out of the facility’s 87 families are Next Step families who were transferred to the facility from other facilities due to non-compliance, documentation, chronic public assistance problems or no longer working to qualify for WAP.

b)

An additional recreation worker is necessary to provide recreation services to approximately 56 school-age children ages 6 years through 16. On the days of the inspection, August 5 - 8, 2008 school-age children and adults were both utilizing the recreation room which was too much for one worker to handle effectively.

c)

The facility failed to provide child-care services for approximately 39 children ages 3 months through 5 years. None of the resident children were attending child-care either on-site or off-site.

CORRECTIVE ACTION: a) DHS must ensure that additional housing personnel are provided in order to ensure that adequate and appropriate housing services are provided to shelter families. DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) New Needs proposal was submitted to Central Office on June 2008 for additional personnel lines. In April 2008 we hired a Community Liaison worker to assist with employment, training and housing referral. On October 2008 DCAS approved 4 additional lines; (2) Principal Community Liaison and (2) Community Liaison to assist with client movement into permanent housing.

b)

Recreation worker - at a minimum, one additional recreation worker must be provided to the facility to assist the recreation coordinator. Separate rooms must be designated if adult activities are provided. During days when public schools are closed for holidays, winter/spring recess and summer vacation, a full day recreation program must be implemented for the school-age children from 8:00AM – 7:00PM. Schoolage children and adults cannot use the same room at the same time for recreation activities since there are different objectives attempting to be achieved by each group. DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) Request for additional personnel lines submitted 6/2008, DHS is awaiting OMB approval. DHS has identified (2) contractors to provide after school services and family empowerment services, contract to being 6/2009. In the interim caseworkers are assigned to assist with recreational activities for children and workshops for adults.

c) • • •

Child-care must be provided on-site for resident children as follows: Hire at a minimum 4 appropriate child-care staff. Provide child-care during the hours from 8:00AM – 6:00PM. Provide appropriate furnishings, manipulative toys, crayons, wheel toys, etc. for the child-care program.

DHS Response: (DHS must be specific and state the time period when the deficiency will be corrected.) DHS is working with this provider to address your concerns regarding childcare and will submit a complete response for this item in subsequent correspondence.

PART B – FACILITY’S RESPONSE TO THE INSPECTION REPORT REPORT DATE: 10/24/08 FACILITY: Auburn Family Residence RESPONSE SUBMITTED BY:

DATE OF RESPONSE:

TELEPHONE:

E-MAIL ADDRESS:

TITLE:

REPORT OF INSPECTION VIOL REGULATION NUMBER 5 900.5(a)(7)&(b) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that all security officers have current state certification cards on file. Five FJC security officers’ licenses had expired or were pending. See Attachment C for names. (Previously cited 04/07/06 & 03/26/07) CORRECTIVE ACTION: Facility administrative staff must ensure that all FJC Security officers have current State certification and copies of current State certification cards are to be available for review. Documentation of security officers’ certification and training must be maintained on premises at all times for OTDA review and inspection. Please see OTDA approved Security Guards forms, Page A12.1 at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Facility Officers do have current State Certification on file and they were current during the state inspection. This is an on-going process due to staff turnover. See attached copies of certification numbers for security staff mentioned in attachment (c).

VIOL REGULATION NUMBER 6 900.6(h)(1) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to obtain copies of all resident preliminary health screen examination forms at the point of admission or within 24-hours after admission to the facility. Six of the twenty-two family case records reviewed lacked copies of medical screen health forms. See Attachment C for names. (Previously cited 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: Social Services staff must obtain and maintain a copy of all family members’ preliminary health screen forms at the point of admission or within 24-hours after admission to the facility. Please see OTDA approved preliminary health screen forms at our new Website: www.otda.state.ny.us/main/bhs.

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Social Service has instituted a “Daily Caseworker Activity Sheet” to assist social service staff in obtaining the “health screen forms and to ensure that they are maintained in the record in a timely manner. Meeting with social service staff was held on 8/22/08 to address this issue and to insure that the Floating Hospital obtain release forms from each client after services are rendered in order to obtain copies of the health screen forms. The Daily Caseworker Activity Sheet is utilized as a goal oriented “tickler” at intake and on-going client and staff meetings to ensure all required documents are included in the case records.

VIOL REGULATION NUMBER 7 900.6(h)(3) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to obtain copies of children’s inoculation history. Three of the twenty-two family case records reviewed lacked copies of the children’s inoculation history. See Attachment C for names. (Previously cited 03/26/07) CORRECTIVE ACTION: Social Services staff must request and obtain inoculation history and file in family case record.

copies

of

children’s

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) As of September 2008 an Auburn staff liaison has been identified and assigned to obtain health screens and inoculation histories from clients upon intake, for those families seen by a medical provider at PATH. In addition we will continue to work twith the Floating Hospital to obtain medical release forms so the site can get the children’s inoculation histories. DHS will address all issues pertaining to client’s preliminary health screening and inoculations.

VIOL REGULATION NUMBER 8 900.10(c)(1)(i) & 900.14(a) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to conduct a comprehensive assessment within 10 days of the family’s admission date. Eight of the twenty-two families’ case records reviewed lacked a complete intake assessment: missing date of admission, education job/employment histories of all adult family members, emergency information, health information or lacked summary of assessed needs. See Attachment C for names. (Previously cited 04/07/06 & 03/26/07)

CORRECTIVE ACTION:

Social Services staff must meet with all family members within two days of their admission date to conduct, at a minimum, a preliminary needs intake review, or a comprehensive assessment. In all cases, a comprehensive assessment (including other adult family members) must be completed within 10 days of the family’s admission date and the Family Case Record Admission/ Assessment form is to be filled out in its entirety. Please see OTDA approved Family Case Record Admission/ Assessment form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency

will be corrected.) Social Service instituted a “Daily Caseworker Activity Sheet”. This form will assist the social service staff in ensuring that each family completes a preleminary needs intake review within two days and a comprehensive ILP within 10 days of the families’ admission. 8/22/08 meeting with social service staff detailed the need for each caseworker to complete the comprehensive assessment and provide a detailed summary of how the family became homeless and make the necessary referral to assist the clients in securing permanent housing. The Daily Caseworker Activity Sheet will also serve as a goal oriented “tickler” for caseworkers to ensure that all required services are provided in a timely manner.

VIOL REGULATION NUMBER 9 900.10(c)(1)(ii) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to review and revise all families Bi-Weekly/Independent Living Plans (ILP’s) on a bi-weekly basis. Eight of the twenty-two family case records reviewed lacked consistent bi-weekly reviews, signatures of all resident adults and omitted the other adult assessed needs on ILP’s. See Attachment C for names. (Previously cited 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: Social Services staff must meet with all families, at a minimum, bi-weekly to review and revise the Service and Bi-Weekly/Independent Living Plan. All family members’ needs must be addressed on the plan and signed by the adult members of the family. Please see OTDA approved Service and Bi-Weekly/ Independent Living Plan form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 8/22/08 a meeting was held with social service staff to ensure that all caseworkers are meeting with their clients daily to complete ILP’s and room checks. At the conclusion of their shifts caseworkers are required to submitted ‘”Caseworker Activity Sheets” to their immediate supervisors for review and signature. On 10/08 DCAS approved additional personnel lines to assist caseworkers in meeting ODTA requirements. Of the 8 case records reviewed 4 families are no longer registered at this facility and 2 families moved into permanent housing. VIOL REGULATION NUMBER 10 900.10(c)(1)(iii) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING:

Facility staff failed to document all direct and indirect family services via progress notes. Six of the twenty-two family case records reviewed lacked consistent, adequate or up-to-date progress notes, lacked family’s eligibility/conditional status, discharge and readmit dates. See Attachment C for names. CORRECTIVE ACTION:

Social Services staff must document direct and indirect family services via progress notes. Progress’ notes must be thoroughly documented throughout the family’s stay at the facility and reflect the changes that occur with the family. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Meeting with social service staff on 8/22/08 emphasized the need to ensure that the ILP’s reflects

all progress or lack of that the families have made since their last ILP and progress notes for all families should be consistent. All supervisors are responsible to review and will sign off on case records daily. Of the 6 records reviewed 4 families are no longer registered at this facility and 1 moved into permanent housing. On 1/08 DCAS approved additional personnel lines to assist caseworkers to provide consistent, adequate and up the date progress notes which will reflect the changes that occur with families.

VIOL REGULATION NUMBER 11 900.10(c)(1)(iii); 900.10(c)(4) & 900.15(c)(4)(v) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to refer all family members to the appropriate service agency within 30 days of each family’s needs assessment. Seven of the twenty-two family case records reviewed failed to demonstrate that all family members were referred within a timely manner, only an initial referral was made, or the form was incomplete. See Attachment C for names. CORRECTIVE ACTION: Social Services staff must continuously assess the needs of all family members and refer such member to the appropriate service agency within 30 days of each assessed need throughout the families’ stay. The Case Management form must be filled out in its entirety. Please see OTDA approved 30 Day Case Management form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Social Service staff has updated its comprehensive list of community based resources. On 9/22/08 this list was distributed to each caseworker and as of 4/08 we hired a community liaison worker to assist with referrals to community based organizations, educational and vocational programs. All referrals are made an ongoing basis to agencies such as HRA/Begin program, HRA job search and career training programs, DHS job fairs and the appropriate services must be well documented in the case files. VIOL REGULATION NUMBER 12 900.10(c)(2)(i)&(ii) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to provide all families with adequate housing assistance as follows: a)

Six of the twenty-two family case records reviewed lacked housing plans developed within ten days of the admission date, incomplete housing plans, or no housing plans. See Attachment C for names. (Previously cited 02/14/05, 04/07/06 & 03/26/07)

CORRECTIVE ACTION: a) Social Services staff must ensure that all family housing intake plans are completed within ten days of the family’s admission date and complete the form in its entirety. Please see OTDA approved Housing Plan form at our new Website: www.otda.state.ny.us/main/bhs.

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Meeting was held on 9/22/08 with all Social Service staff, Housing Specialist and Community Liaison Worker to review what must be documented in client’s case records on housing. In addition to the Housing specialist, all caseworkers are currently assisting all clients on their caseloads with housing issues, documentation and follow-up which are documented in client’s case files. Consequently individual case conferences were held with families noted in Appendix C regarding maintaining housing appointments. All supervisors will review and sign off on case records to ensure compliance FINDING: b) Nine of the twenty-two family case records reviewed lacked housing notes or up-to-date housing notes. See Attachment C for names. (Previously cited 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: b) Social Services staff must meet with families within ten days of the family admission date to complete the housing intake plan and thereafter at least once a month or as often as needed once the family becomes certified for a housing program. Documentation is to include barriers which may prevent them from obtaining housing timely. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 9/22/08 meeting was held with Social Service Staff and Housing Specialist. The Housing Specialist has been instructed to monitor the on-site list daily and use it has an indication as to when each families 10th day in the facility is approaching. Housing specialist is meeting regularly regarding their housing options, however two of the cases reviewed are families who are undocumented. Although these two families presents special challenges interms of securing housing, the staff is working with them to find housing. All caseworkers will indicate in the “housing section” of client’s files when each family is eligible and barriers that may prevent them from obtaining permanent housing.

VIOL REGULATION NUMBER 13 900.11(a)(1) & 900.14(a) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility maintains monthly chronological admissions and discharge registry forms; however, data received was only for previous six months. CORRECTIVE ACTION: Facility administrator is to continue to maintain chronological admission and discharge registries of all families as they are admitted and discharged from the facility. The registries must be available for review during the inspection for at least one year. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Monthly chronological admissions and discharge registration forms are maintained on site for over one year. All forms over 1 year are removed from current file and placed in archive. Auburn facility is willing to present this information to OTDA if the need still exists. Moving forward, this information will be kept in the log for 1 year.

VIOL REGULATION NUMBER 14 900.11(a)(1) & 900.14(a) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to maintain a daily census of all (Previously cited 01/09/04, 02/14/05, 04/07/06 & 03/26/07)

its

residents.

CORRECTIVE ACTION: The facility must maintain the census form as required in provision 900.16(f), which includes the documentation of the presence and absence of all families residing in the facility on a daily basis. The census documents must clearly distinguish all family absences, curfew violations, discharges and total billing days per family per month in which reimbursements are claimed. The facility must also add the symbol (c) Curfew violation to the other symbols that are listed on the bottom of the form. Please see OTDA approved Family Census form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 9/1/08 the ODTA Family approved census form was implemented and reviewed with all Social Service personnel. This form documents the presence or absence of all families including families missing curfews. VIOL REGULATION NUMBER 15 900.11(a)(2) & 900.15(4)(iv) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to maintain a master school-age children’s indicating their departure to school. (Previously cited 03/26/07)

roster

CORRECTIVE ACTION: Although the Department of Education family assistant provides assistance with children departing for school, it is the facility’s staff responsibility to provide and maintain records of school-age children’s departure. The master school-age roster departure form is to include the following: family name, child’s name, assigned room number, families’ admission date into the facility, school enrollment date of each child, name of school, grade and check-off system by staff indicating children’s departure or non-departure to school. Please see OTDA approved Daily School Departure/Attendance form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 9/2/08 the OTDA approved Daily School Departure/ Attendance Form was implemented. Social Service Staff met with the Board of Education Liaison to review the use of the School age Master Roster. This form must document school age children’s departure or non-departure, attendance, school enrollment date, name of school etc.

VIOL REGULATION NUMBER 16 900.11(a)(4) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING:

The facility failed to maintain accurate emergency information on each family at the ASW post.

CORRECTIVE ACTION: The facility’s administrative staff must ensure that emergency information is accessible and available at all times when Social Services staff is not on the premises. The file is to be updated and purged as families are admitted and discharged into and out of the facility. Please see OTDA approved Emergency Family Information form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) The facility has maintained Emergency Information on all clients in their case files records and centrally located in the ASW’s office. A social service supervisor has been assigned to monitor, review and update these files to ensure accuracy and that they are maintained current.

VIOL REGULATION NUMBER 17 900.11(a)(5) & 900.9(c)(6) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to attach or to include resolution statements consistently to all incident report forms when documenting facility incidents and failed to respond in writing to residents’ complaints. CORRECTIVE ACTION: The facility must include room numbers of residents involved in incidents and attach a resolution statement consistently to all incident reports. All incidents along with the resolution must be centrally filed. In addition, all incidents are to be recorded on a master summary log which includes the following: Date, Resident name, Room #, Category of incident and the Initials of staff filing the incident. The incidents and master summary log must be available for OTDA review and inspection. Additionally, all complaints must be responded to in writing and a copy must be filed in the family case record. Please see OTDA approved Report Forms and Resident Suggestion/ Complaint form at our new Website: www.otda.state.ny.us/main/bhs. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 8/22/08 meeting was held with all Social Service and Operational supervisors. A supervisor was assigned to monitor and follow-up to all incidents and client complaints. Suggestion/ complaint form reviewed with clients at house meeting and all concerns will be forwarded to the Director for follow-up and resolution. This information is kept in the director’s office. All complaints will be responded to in writing by the director or designee.

VIOL REGULATION NUMBER 18 900.5(a)(4) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that residents eliminate the excessive use of extension cords in their rooms. Approximately 80% of the Residents utilize extension cords in their room. CORRECTIVE ACTION: The facility must provide additional code compliant electrical outlets in Resident rooms.

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) All extension cords have been removed. Case workers bi-weekly inspection will ensure that extension cords are not in use. VIOL REGULATION NUMBER 19 900.5(a)(1); 900.5(a)(4) & 900.12(a) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that the building was maintained in a good state of repair as follows: At the time of inspection, Room 3-381 was off-line due to the lack of heat due in part to drafty non-storm windows. (Previously cited 01/09/04, 02/14/05, 04/07/06 & 03/26/07) CORRECTIVE ACTION: The facility plans to have major exterior brick work done to the facility and based on Capital Project NYC DDC Project# HR115AUBX the project will be completed by spring of “09”. Provide us with an update concerning this project. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Exterior brick pointing commenced on 2/18/08 and as of the time of this report floors 9-2 are completed. It is estimated that weather permitting the installation of new windows with screens and mini blinds will start by the 1st week of December 2008. VIOL REGULATION NUMBER 20 900.5(a)(6) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The following documents were not available for review during this visit: a- The elevator repair records; b- The boiler repair/inspection records; and, c- The smoke/fire alarm system. CORRECTIVE ACTION: The facility must provide this office with the above named records and sign offs for the annual inspections and maintenance documentation. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) The elevator repair records are maintained on site. The boiler repair and inspection records are maintained by Cumberland Hospital since the boiler which provides heat is located on the side of Cumberland Hospital, however see attached “Boiler inspection report”. On August 2008 RNH Electric Company commenced installing the Fire Alarm System at the facility and it is estimated that the work will be completed by July 31, 2009. In the meantime, portable smoke detectors are installed throughout the facility.

VIOL REGULATION NUMBER 21 900.11(b)(2) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that at all times at least one member of the staff was a nurse or have a minimum of eight hours of basic first aid training. CORRECTIVE ACTION: The facility must ensure that at least one staff member on each shift, 24 hours per day 7 days per week have a minimum of eight hours of basic first aid training or be a nurse. Please provide this office with the Medical Staff schedule which shows 24 hour coverage 7 days a week. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On August 24, 2008 central office (Training Unit) was provided with a list of personnel on all 3 shifts that require “First Aid training”. At this time 3 supervisors 1 from each shift have been trained in “first aid/ CPR” and the facility is covered as required.

VIOL REGULATION NUMBER 22 900.12(e)(8) SPECIFIC ITEMS OF NON COMPLIANCE AND CORRECTIVE ACTION REQUIRED: FINDING: The facility failed to ensure that all resident sleeping areas have shades or other appropriate window covering to ensure privacy. Approximately 90% of the resident bedrooms were without such provision. (Previously cited 10/03/94, 06/13/95, 07/18/96, 03/28/97, 04/14/99, 11/15/01, 12/20/02, 01/09/04, 02/14/05, 04/07/06 and 03/26/07) CORRECTIVE ACTION: The facility must apartment windows.

provide

privacy

shades

or

a

window

covering

for

all

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 2/18/08 Capital project for the installation of windows with shades and mini blinds commenced and is on -going. It is projected the work will be completed by July 2009.

ATTACHMENT A Inspector’s Recommendations and/or Comments 1. Case Notes Documentation Facility administrator must encourage social services staff to use the computers to type progress and housing notes; and to file documents in logical sequence in appropriate sections. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) Meeting held on 8/22/08 with all social service staff (1) to institute the typing of progress and housing notes (2) re-organzie the caserecords so as to maintain documents sequentially and to standardize all sections.

ATTACHMENT B MAINTENANCE VIOLATIONS PLEASE TYPE YOUR CORRECTIVE ACTION RESPONSE IN BOLD UNDERNEATH EACH ITEM 1) Complaints of water bugs, fleas and centipedes: Room 733. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) we currently have a contract with USA Exterminators Inc. The exterminator company services the facility monthly and provides extra services when problems are identified due to the construction.

2)

a- Emergency entry/exit into Rooms was blocked by furniture/belongings near the door: Rooms 824 & 755. b- The 2nd floor janitor’s closet was not provided with a door. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 8/24/08 residents in rooms 825 & 755 were conference and furniture items were removed from obstructing the entrance of the rooms. b- On 8/24/08 Work Order was submitted for the installation of door to janitor’s closet, (Slop sink).

3)

a- The dining room floor cannot be cleaned; the black spots/dots visual on the floor results when the floor is stripped/buffed the black undercoating protrudes thru the outer coating which comes off when the floor is cleaned. b- The ceiling pipes in the Dining Room were covered with an accumulation of dust (the pipe side to the ceiling). Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) a- On August 24, 2008 work order was submitted for the replacement of the dining room floor. We are awaiting decision as to whether this will constitute a “Capital Project” expense.

4)

a- Dead mouse on glue board: Room 466-6. b- Rodent problem: Room 757 (radiator entry holes). Facility Response: (The facility must be specific and state the time period when the deficiency

will be corrected.) a- USA Exterminators Inc company services the facility monthly and upon request bi-monthly due to the construction. b- Work order submitted on June 2008 to have all radiator holes covered.

5)

There were no pallets or shelves to keep bags of clean linen off the floor and against the wall. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On 8/24/08 shelves were ordered and once received will be installed in the linen room.

6) Beeping smoke detector: Rooms 823, 383 & 376. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) DHS dispatches FMD staff who regularly addresses Fire Safety Issues. On September 3, 2008 all smoke detectors were serviced and batteries replaced.

7) Dresser drawer is missing and/or broken: Rooms 624-5, 624-6 & 756. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected. On September 10, 2008 shipment of dressers was received and all broken or damaged dressers have been discarded and replaced for all residents.

8)

Padlocks or sliding bolts were attached to the corridor side doors. These locks are not the safety locks which would allow an individual locked inside the room to exit when the outside lock is engaged. a- Kitchen store room door b- Storerooms throughout the building Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On August 24, 2008 work orders were submitted to have “Lock smith” replace padlocks and sliding bolts with safety locks.

Stairwell “A” (1st floor) door and “B” stairwell 6th floor were maintained in the open position. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On September 5, 2008 meeting was held with contracted agency FJC guards to emphasize the need to maintain all stairwell doors closed at all times.

9)

10) Floor tiles were missing: Rooms 624-3 and 828. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On September 5, 2008 work orders were submitted to have missing tiles in rooms 624-3 and 828 replaced.

11)

Hot water ran constantly down the drain: Room 754.

Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On September 5, 2008 water faucet in room 754 was repaired.

12) Bathroom was filthy; tub and floor needed to be cleaned: Room 743. Facility Response: (The facility must be specific and state the time period when the deficiency will be corrected.) On September 3, 2008 staff instructed to thoroughly clean tub, and floor in room 743.

CORRECTIVE ACTION: Clean, repair, replace and/or restore the above items/make the appropriate intervention and referrals.