Corrective Action Plan Report Page 1 of 353:0? Office of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant incident (TAP Status: Implemented NIMRS Incident#: Incident Status: Closed (TAP Due Date: ?it'll/2016 2:39:01 PM Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: l. Any Offense Substantiated by The NYS Justice Center? Determination Letter Received? No Date Received: Unknown Corrective Action Details Corrective Action 1 Corrective Action Type: StaffEducation/'l'raining Implementation Status: Fully implemented Corrective Action Description: was ol' the need to include Risk Management and possiny Justice (?enler in allegations of this nature. Implementation Date: 1052512016 Approved: Person Responsible: Dr. Kaplan Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report Page 1 of $5309" Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident Status: Implemented NIMRS Incident?: Incident Status: Closed (ZAP Due Date: 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact .IC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS Justice Center? 1; nltnou Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Employee Counseling/'Reprimand Implementation Status: Fully Corrective Action Description: Referred to Human Resource Department for appropriate action Implementation Date: 10/7/2016 Approved: Person Responsible: Patricia Bardo Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report Page 1 of 1 353030? Of?ce of mummy Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident Status: Implemented NIMRS Incident#: Incident Status: Closed CAP Due Date: 7x"25/2016 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact .IC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS Justice I (enter? 1. \n Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Medication Change Implementation Status: Fully Implemented Corrective Action Description: Medical specialist reviewed incident and it appears the increased dose ofLyrica. along with his usual medications. caused a multiplicative effect. Care will be exercised in the future concerning sedating medication in combination with other sedating medications. Discussion with other prescribers will take place when a medication change could happen. Implementation Date: 93?83?2016 Approved: Person Responsible: Dr. Palumbo Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report 353010!? Of?ce of onoanmm Mental Health Page I of CORRECTIVE ACTION PLAN Incident Details Incident ID: Incident Type: Signi?cant Incident Status: Implemented NIMRS Incident#: Incident Status: Closed CAP Due Date: 7.x?22x?2016 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS Justice Center? In nown Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Physical Plant Improvement Implementation Status: Fully Implemented Corrective Action Description: Environmental Reviews will be conducted. as well as reinforcing the need for continuous safety review and monitoring by staff Implementation Date: 918/2016 Approved: Person Responsible: 'I?om l'mina Revision Required: Measure of Effectiveness: Attachments for Corrective Action I attachments Corrective Action Plan Report Page I of I 2533"" Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident CAP Status: Implemented NIMRS Incident#: Incident Status: Closed (TAP Due Date: 12:00:00 AM CAP Implemented: CAP Manager Contact Details (?ap Manager: Laurie Turnbull Phone Contact 315-765-3696] (Work) JC Determination Details Issue of Concerns: I. Offense Suhstantiated by The NYS Justice Unknown Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: StaffEducation/Training Implementation Status: Fully Implemented Corrective Action Description: Refer to (?hiet~ for follow up with stall? and review of procedure regarding ?exi pens Implementation Date: Approved: Person Responsible: Ken Paparella Revision Required: Measure of Effectiveness: Attachments for Corrective Action I attachments. Corrective Action Plan Report Page I of Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details Incident ID: Incident Type: Abuse and Neglect Status: Implemented Incident?: Incident Status: Closed Due Date: 12/8/20l6 l2:00:00 AM Implemented: I If] 5.0.016 l2:00:00 AM CAP Manager Contact Details (?ap Manager: Laurie Tumbull E-Mail: Phone (?ontaet 315-765-3661 (Work) .IC Determination Details . I. Program/Sewices/Treatment. 2. 3. thsical 4. Issue of( oncernsersonnel? rainingallegation was substantiated) Any Offense Suhstantiated by The NYS Justice (Tentcr? ?5 Determination Letter Received? Yes Date Received: 12:00:00 AM Corrective Action Details Corrective Action 1 (?orrective Action Type: Physical Plant Implementation Status: l'ull) Implemented (?orrective Action Description: it is recommended that video surveillance cameras be installed in the dining area for the protection of patients and staff Implementation Date: 10"25/2016 Approved: Person Responsible: Tim Lamitie Revision Required: Measure of Effectiveness: Attachments for Corrective Action I Ia?lit-i??nnu-s 45244_I?reliminary Hy: enopjaw an 2:56:26 PM Corrective Action 2 Corrective Action Type: limployee Counseling/Reprimand Implementation Status: Fully Implemented Corrective Action Description: The employee has retired Implementation Date: 9/30?2016 Approved: Person Responsible: Ken Paparella Revision Required: Measure of Effectiveness: Attachments for Corrective Action 2 Retirement White 09 09 16.docx I Mum/yd lit.- cnopjatv an I l"'20l6 I2z03zll PM Corrective Action Plan Report Page 1 of 5,530?? Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details JC. Incident ID: Incident Type: Abuse and Neglect CAP Status: Implemented MMRS Incident#: Incident Status: Closed CAP Due Date: [l\2\.1l3.20l6 1-00.00 CAP Implemented: 1 1/1 1/2016 12:00:00 AM CAP Manager Contact Details Cap Manager: Laurie Turnbull E-Mail: omh.ny.gov Phone Contact 315-765-3061 (Work) JC Determination Details Issue of Concerns: 1. Physical l?lant?linvironmental Any Offense Substantiated by The NYS Justice Center? Determination Letter Received? Yes Date Received: 9514/2016 12:00:00 AM No Corrective Action Details Corrective Action 1 Corrective Action Type: Physical Plant Improvement Implementation Status: l?ully Implemented Corrective Action Description: It is recommended that video surveillance cameras be installed in the dining room for the protection of patients and staff. Implementation Date: Approved: Person Responsible: ?I'im Lamitie Revision Required: Measure of Effectiveness: Attachments for Corrective Action I 45244_Preliminar_\' cnopjaw on 1025:2016 3:05:23 PM Corrective Action Plan Report Page 1 of 253'?? Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details Incident ID: Incident Type: Signi?cant Incident CAP Status: Implemented NIMRS Incident#: Incident Status: Closed CAP Due Date: 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E?Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS Justice Center? Determination Letter Received? No Date Received: nknown Corrective Action Details Corrective Action 1 Corrective Action Type: Stal?l' liducationxTraining Implementation Status: Fully Implemented Corrective Action Description: Refer to the Social Work Supervisor for appropriate follow up with primary therapist regarding reporting requirements to the Justice Center Implementation Date: Approved: Person Responsible: (?hris Burrows Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report Page 1 of 2533*? Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Significant Incident Status: Implemented NIMRS Incident Status: Closed (SAP Due Date: 71"l6i?2016 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS .Iusticc (Tcnter? Determination Letter Received? No Date Received: lnknown Corrective Action Details Corrective Action 1 Corrective Action Type: Staffliducation"l?raining Implementation Status: Fully Implemented Corrective Action Description: Refer to Director of Inpatient Social Work to review Policy 3.8 Comprehensive suicide Risk Assessment Process with the Social Worker and complete a training sheet to he sent to lid 'l?raining. Implementation Date: 8/8520 6 Approved: Person Responsible: Chris Burrows Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report Page 1 of 1 3530?? Of?ce of Quantum" Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident 'l?ype: Abuse and Neglect CAP Status: Implemented NIMRS lncident?: Incident Status: Closed CAP Due Date: 12?0"? CAP Implemented: ll/l 5/2016 12:00:00 AM CAP Manager Contact Details Cap Manager; Laurie 'l'urnhull E-Mail: Phone Contact 315-765-3661 (Work) JC Determination Details l. 2. Personnelx'l'raining. 3. Cat 354(a 3 or 4 allegation was Issue of Cone ns substantiated) Any Offense Suhstantiated by The NYS Justice Center? Determination Letter Received? Yes Date Received: 812352016 12:00:00 AM Corrective Action Details Corrective Action 1 Corrective Action Type: Staff Educationi?lraining Implementation Status: Fully Implemented Corrective Action Description: Refer to Chief to provide a review ofthc constant Observation Policy with staff. Implementation Date: Iii/4,2016 Approved: Person Responsible: Ken Paparella Revision Required: Measure of Effectiveness: Attachments for Corrective Action I cnopjaw UH ln'2016 11:55:59 AM Corrective Action Plan Report Page 1 of 1 553010? Of?ce of mm" Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident (TAP Status: Implemented NIMRS lncident#: Incident Status: Closed CAP Due Date: 15.12016 12:00:00 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any O?'ense Suhstantiated by The NYS Justice Center? linknou Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Physical Plant Improvement Implementation Status: Fully Implemented Corrective Action Description: Refer to Committee for an environmental review ofthe Gym-"Activity Center Implementation Date: :?2016 Approved: Person Responsible: 'l?im Lamitie Revision Required: Measure of Effectiveness: Attachments for Corrective Action 1 attachments. Corrective Action Plan Report Page I of 1 Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident CAP Status: Implemented NIMRS Incident#: Incident Status: Closed CAP Due Date: 13.52016 3:29:29 PM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: l. Personnel-"training Any Offense Substantiatcd by The NYS Justice . . Center? linknon Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Staff [Educationu?Training Implementation Status: Fully Implemented Corrective Action Description: (?hiel?met with involved SIITA and reviewed the Constant Obs Policy 3.2 Implementation Date: I Approved: Person Responsible: Ken Paparclla Revision Required: Measure of Effectiveness: Attachments for Corrective Action I allat.'lznzent.s'. Corrective Action Plan Report 5530?? Of?ce of Mental Health CORRECTIVE ACTION PLAN Incident Details Page 1 of 1 Implemented: JC Incident ID: Incident 'l?ype: Signi?cant Incident CAP Status: Implemented NIMRS lncident#: Incident Status: Closed Due Date: 12:00:00 AM CAP Manager Contact Details Cap Manager: Laurie 'l'urnhull E-Mail: Phone Contact 315-765-3661 (Work) JC Determination Details Issue of Concerns: 1. Other Any Offense Substantiated by The NYS Justice Center? Determination Letter Received? No Date Received: Unknown Corrective Action Details Corrective Action 1 Corrective Action Type: Other Implementation Status: Fully Implemented Corrective Action Description: Add alert into the system to separate patients Implementation Date: 7.5283016 Approved: Person Responsible: Ken Paparella Revision Required: Measure of Effectiveness: Attachments for Corrective Action I attachments. Corrective Action Plan Report Page I of 353030" Of?ce of opmumn Mental Health CORRECTIVE ACTION PLAN Incident Details Incident ID: Incident Type: Signi?cant Incident Status: Implemented NIMRS lncident?: Incident Status: Closed (ZAP Due Date: 6/16/2016 AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Suhstantiatetl by The NYS Justice . . Center? I: nknoun Determination Letter Received? No Date Received: Corrective Action Details Corrective Action 1 Corrective Action Type: Stal?t? Education/Training Implementation Status: Fully Implemented Corrective Action Description: Reminder e-mail sent to all SIITA staff reminding ot?importancc of maintaining proper supervision of patients/patient areas Implementation Date: [#2016 Approved: Person Responsible: Ken Paparella Revision Required: Measure of Effectiveness: Attachments for Corrective Action I No attachments. Corrective Action Plan Report Page I of 1 NEW YORK sun. or oncmuum Office of Mental Health CORRECTIVE ACTION PLAN Incident Details JC Incident ID: Incident Type: Signi?cant Incident Status: Implemented NIMRS lncident#: Incident Status: Closed CAP Due Date: AM CAP Implemented: CAP Manager Contact Details Cap Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Substantiated by The NYS Justice Center? Determination Letter Received? No Date Received: ll nknown Corrective Action Details Corrective Action 1 Corrective Action Type: Other Implementation Status: I?ully Implemented Corrective Action Description: See IRC Findings Implementation Date: 5:26.52016 Approved: Person Responsible: Laurie 'I?umbull Revision Required: Measure of Effectiveness: Attachments for Corrective Action I ullaclmzenls. Corrective Action Plan Report Page 1 of 1 2533'? Office of Mental Health CORRECTIVE ACTION PLAN Incident Details Incident ID: Incident Type: Signi?cant Incident Status: lmplemented NIMRS Incident#: Incident Status: Closed (TAP Due Date: 6/30/2016 12:00:00 AM Implemented: CAP Manager Contact Details Manager: E-Mail: Phone Contact JC Determination Details Issue of Concerns: Any Offense Substantiatcd by The NYS Justice Center? Determination Letter Received? No Date Received: ll nknown Corrective Action Details Corrective Action 1 Corrective Action Type: Physical Plant Improvement Implementation Status: Fully Implemented Corrective Action Description: Refer to for environmental review of the lire door tags Implementation Date: Approved: Person Responsible: Tim Lamitie Revision Required: Measure of Effectiveness: Attachments for Corrective Action I