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Date ArticleType
12/6/2016 Regulatory
September and October 2016 Residential Tag Summary

The Indiana State Department of Health conducted 13 surveys in the residential facilities in the month of September with 6 of the 13 or 46.15 percent of licensure that are deficiency free.  A total of 36 residential tags with 2 Offence Tags.  One Offence Tag was in Resident Rights for failure to ensure that all residents are free from abuse, corporal punishment, neglect, and involuntary seclusion and a Health Services tag for failure to develop and implement policies for investigating and responding to complaints when made known and grievances made by an individual resident, a resident council or family council, or both, a family member, family group, or other individuals. 

Residential tags were also cited in the following areas:

Tag 273 (10 times) – Food and Nutrition for failure to maintain food preparation and services areas in accordance with state and local sanitation and safe food handling standards. 
Tag 144 (3times) – Sanitation and Safety Standards for failure to maintain their building and grounds in a clean, orderly, and good state of repair to provide for the reasonable comfort of all residents.
Tag 117 (3 times) – Personal for failure to ensure that staff is sufficient in number, qualifications, and training to provide the 24-hour scheduled and unscheduled needs of the residents.
Tag 90 (2 times) – Administration and Management for failure to ensure administrator maintained overall management of the facility, including the responsibility to inform ISDH within 24 hours of an unusual occurrence that threatens the health or safety of a resident.
Tag 214 (2 times) – Evaluation for failure to initiate an evaluation of the individual needs of each resident prior to admission and upon change of condition thereafter, with a licensed nurse evaluating each resident’s need for nursing care.
Tag 217 (2 times) – Evaluation for failure to use appropriately trained staff to complete an evaluation that identified the scope. Frequency, need, and resident’s preference for the services to be provided by the facility; review and revise the plan as appropriate; and have the resident sign and date the plan.
Tag 247 (2 times) – Health Services for failure to ensure that any error in medication administration is noted in the resident’s record and/or the physician is notified of any such error when there is actual or potential harm to the resident.
 
All other tags were citied once for tag 35,41,55,149,152,272,298,300,304, and 414.

The Indiana State Department of Health conducted 7 surveys in October 2016.  There were 4 or 57.14 percent of licensure that are deficiency free.  There was a total of 33 residential tags and 5 of the 33 tags were Offence Tags.  All five of the Offence tags were for Health Services Tag 241 for failure to have the medication (s) ordered by the resident’s physician administered by licensed nursing personnel or QMAs.

Residential tags were cited for the following tag:

F273 (4 times) – Food and Nutritional Services for failure to maintain food preparation and services areas in accordance with state and local sanitation and safe food handling standards. 
F90 (3 times) – Administration and Management for failure to ensure administrator maintained overall management of the facility, including the responsibility to inform ISDH within 24 hours of an unusual occurrence that threatens the health or safety of a resident.
F117 (3 times) – Personnel for failure to ensure that staff is sufficient in number, qualifications, and training to provide the 24-hour scheduled and unscheduled needs of residents.
F144 (3 times) – Sanitation and Safety Standards for failure to maintain their building and grounds in a clean, orderly, and good state of repair to provide for the reasonable comfort of all residents.
F217 (3 times) – Evaluation for failure to use appropriately trained staff to complete an evaluation that identified and documented the scope, frequently, need, and resident’s preference for the services to be provided by the facility; review and revise the plan as appropriate; and have the resident sign and date the plan.
F036 (2 times) – Resident Rights for failure to immediately consult a resident’s physician and legal representative after noticing a significant decline in the resident’s physical, mental, or psychosocial status and/or a need to alter treatment significantly.
There was a noted trend in citation under Pharmaceutical Services for F298 (2 times), F300 (1 time), and F302 (1 time). 
F298 – the facility failed to ensure a consultant pharmacist shall be employed, or under contract, and shall: (A) be responsible for the duties as specified in 856 IAC 1-7;  (B) review the drug handling and storage practices in the facility; (C) provide consultation on methods and procedures of ordering, storing, administering, and disposing of drugs as well as medication record keeping; (D) report, in writing, to the administrator or his or her designee any irregularities in dispensing or administration of drugs; and € review the drug regimen of each resident receiving these services at least once every sixty (60) days.
F300 – The facility failed to ensure over-the-counter medications, prescription drugs, and biologicals used in the facility must be labeled in accordance with currently accepted professional principals and include the appropriate accessory and cautionary instructions and the expiration date.
F302 – The facility failed to ensure over-the-counter medications were identified with the following: (A) Residents name. (B) Physician name. (C) Expiration date. (D) Name of the drug. (E) Strength.

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