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Date ArticleType
2/7/2017 Regulatory
G/IJ/SSQC Citation Update

The Indiana State Department of Health conducted a total of 34 recertification surveys for the month of December 2016. Of the 53 recertification surveys,  two or 5.88 percent were deficiency free. There was a total of 13 G level federal tags cited in 10 locations throughout Indiana. The most frequently cited G level federal tags were for F 309 (3 times) and F314 (3 times). F309 was cited in two locations for failure to provide timely pain management and in one location for failure assess, monitor intake and output, urinary catheter care, and PEG-tube care including tube feeding which resulted in a hospitalization. F314 was cited for failure to ensure pressure ulcers were assessed accurately, failure to implement prevention interventions for known risk, physician orders were followed to prevent development of pressure ulcers or worsening of existing pressure ulcers. F314 was also cited for failure to measure pressure ulcers timely. Please note that there are several new surveyors and the focus is on Pain and prevention and management of Skin. I recommend each skilled nursing facility to review your current Skin and Pain Management program policy and procedures to ensure compliance. A review now can prevent G or higher level deficiencies in the future.
There were Four IJs and four SSQC citations for the month of December:
F225 – IJ/QC for failure to ensure that staff immediately reported allegations of verbal abuse to the Administrator for three residents which resulted in failure of the facility to implement measures to protect all facility residents from further potential abuse during the investigation of the three different allegations of abuse.
F225 – QC for failure to ensure employee records had reference checks and/or criminal background checks completed timely and/or thoroughly for more than one employee records reviewed. This had the potential to affect all residents residing in the facility.
F226 – QC for failure to ensure facility policy and procedure for abuse prevention was followed for more than one employee records reviewed. This had the potential to affect all residents residing in the facility.
F323 – IJ/QC for failure to follow facility policy for elopement of a resident who eloped and was outside the facility for greater than 20 minutes with whereabouts unknown.
F257 – IJ/QC for failure to ensure temperature was maintained above 71 degrees which resulted in a threat to the residents who were living in the cold environment.
F155 – IJ for failure to follow the facility CPR policy to complete advance directives as ordered by the physician as directed by the resident or responsible party. The facility also failed to assure advance directives orders and the resident wishes matched. A resident did not receive CPR as ordered by the physician.

The Quarterly Compliance and Education Update will be provided to members on February 22, 2017 from 9-12 via Webinar. There are several new surveyors in Indiana and the information about trends resulting in higher level deficiencies will be discussed in detail.

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