Failure to Timely Submit Termination Forms for CHRC
Summary
The deficiency identified during the Standard survey was the failure to submit the Termination Form 105 to the New York State Department of Health Criminal History Record Check (CHRC) program within the required thirty-day period after an employee was reassigned or terminated. This issue affected three out of twelve personnel files reviewed. Specifically, the facility did not submit the required termination forms for two housekeeping aides and one certified nurse assistant within the stipulated timeframe. The policy and procedure titled Criminal History Record Check, last modified in April 2024, required the Human Resources Professional to complete the Subject Individual Termination Form for CHRC via the Health Commerce System website within 30 days of a staff member's termination. The personnel records revealed that Housekeeping Aide #1 and Housekeeping Aide #2 received a Pending Denial letter, with their last working days in March 2023, but their Termination Forms were not submitted until May 2023. Similarly, Certified Nurse Aide #8, who did not work in the facility, had a Hold in Abeyance letter dated June 2024, but the Termination Form was not submitted until August 2024. During an interview, the Human Resources Manager, who assumed their position in May 2023, stated they were unaware of the delay in submitting the forms until they conducted a personnel file review. The manager acknowledged that the Termination Form for Certified Nurse Aide #8 should have been submitted by July 2024.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The deficient practice has been corrected as required by regulation. The CHRC active roster review shows compliance at this time. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. The CHRC active roster review shows compliance at this time and no recent issues have been identified. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Human resource manager will in-service the recruitment coordinator on the CHRC policy, and the procedure/timing related to removal of terminated employees from the CHRC list. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit of the CHRC active roster will be conducted every 28 days, over the course of the next six months to ensure that only current employees are active. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
