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Date ArticleType
7/7/2016 Regulatory
G/IJ/SSQC Citation Update

There were a total of 38 recertification surveys completed by the Indiana State Department of Health in the month of May and of those 6 (15.79%) were found to be deficiency free. There were no IJ/SSQC tags cited for the month of May.

There were a total of 18 G level federal tags cited in 13 locations and 11 of the 18 were cited for F323 for failure to ensure the resident environment remains as free from accident hazards as is possible, and failure to ensure each resident receives adequate supervision and assistance devices to prevent accidents. List below are specifics:

• Failure to prevent a dependent resident from falling forward out of her wheel chair while being propelled.
• Failure to apply heat pack therapy with adequate supervision, resulting is second degree burn.
• Failure to ensure a wheel chair was in good repair to prevent injury. A resident incurred a fracture related to a broken wheel chair leading to an infected surgical wound with MRSA, requiring antibiotics and isolation.
• Failure to comprehensively assess depressed behaviors for a resident with documented history of behaviors
• Failure to ensure adequate supervision during transfers with a sit and lift.
• Failure to complete a root cause and analysis and develop and implement interventions to prevent repeated falls.

There were a total of 3 Federal tags cited for F309 for failure to provide psychiatric services timely, failure to provide pain medication to resident prior to a dressing change and failure to ensure a urine specimen was transported to laboratory and not notifying physician of the delay in transporting the urine specimen. Other isolated citations were received at the G level for the following:

• F314 – The facility failed to ensure preventive interventions were in place to prevent a new pressure ulcer.
• F323 – The facility failed to ensure the resident remained free from verbal abuse.
• F157 – The facility failed to notify the physician of changes related to a resident who sustained a fall which resulted in a total wound dehiscence (surgical complication in which a wound ruptured along the surgical incision)

To prevent deficiencies, ensure you have a systematic approach to compliance.
1. Establish policies and procedures and controls. (review policies annually)
2. Exercise effective compliance oversight and designate responsibility. (job descriptions)
3. Exercise due diligence with hiring practices and abuse prohibition.
4. Communicate and educate employees. (competency evaluations, annual education calendar, and orientation – general and department specific)
5. Monitor compliance and effectiveness of current adherence to policy and procedures. (QAPI Program)
6. Ensure a culture of constant promotion of compliance and resident/employee safety.
7. Respond appropriately to incidents timely and take steps to prevention future incidents (root cause and analysis, grievance reporting and response, postings, compliance hot line, complaint process)

If you have any questions or need assistance, please contact ldavenport@ihca.org.