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Date ArticleType
3/5/2018 Regulatory
Residential Citation Update for January – A proactive approach to your upcoming residential survey!

The Indiana State Board of Health conducted nine surveys in the month of January.  Of those, two (22.22 %) were found to be deficiency free. There was a total of 74 residential tags citations with nine of them being offense tags. 

The following are the offensive tags:
0241(5 times) – Health Service Offense for failure to ensure the administration of medications and the provision of residential nursing care shall be as ordered by the resident’s physician and shall be supervised by a licensed nurse on the premises or on call. 

0052(2 times) –  Residents’ Rights Offense for failure to ensure residents right to be free from: 10 sexual abuse; (2) physical abuse; (3) mental abuse; (4) corporal punishment; (5) neglect; and (6) involuntary seclusion.

0051(2 times) -- Residents’ Right Offense for failure to ensure residents were free from physical abuse or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms. 

The following are residential citations for January:
0273(8 times) – Food and Nutritional Services Deficiency for failure to ensure all food preparation and serving areas (excluding areas in residents’ units) are maintained in accordance with state and local sanitation and safe food handling standards.

0036(7 times) – Residents’ Rights Deficiency for failure to ensure the facility immediately consulted the resident’s physician and the resident’s legal representative when the facility has noticed: (1) a significant decline in the resident’s physical, mental, or psychosocial status; or (2) a need to alter treatment significantly, that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.

0090(6 times) – Administration and Management Deficiency for failure to inform the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident. 

0217(6 times) – Evaluation Deficiency for failure to ensure identify and document the services to be provided by the facility after completion of an evaluation.  Services offered shall be reviewed and revised as appropriate and discussed by the resident and facility as needs or desires change.  The service plan shall be signed and dated by the resident, and a copy of the service plan shall be given to the resident upon request.  If administration of medications or the provision of residential nursing services, or both, is needed, a licensed nurse shall be involved in identification and documentation of the services to be provided. 

0117(5 times) – Personnel Non-compliance for failure to ensure staff was sufficient in number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hour scheduled and unscheduled needs of the residents and services provided.  Providers failed to ensure a minimum of one (1) awake staff person, with current CPR and first aide certificates, were on site always. 

0154(4times) – Sanitation and Safety Standards Deficiency for failure to keep all kitchen areas, common dining areas equipment, and utensils clean, free from litter and rubbish, and maintained in good repair. 

0214(4 times) – Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident shall be initiated prior to admission and updated at least semiannually and upon a known substantial change in the resident’s condition, or more often at the resident’s or facility’s request.  A licensed nurse shall evaluate the nursing needs of the resident.

0272(3 times) – Food an Nutritional Services Deficiency for failure to ensure all food is served at a safe and appropriate temperature. 

0275(2 times) – Food and Nutritional Services Deficiency for failure to ensure diet orders are reviewed and revised by the physician as the resident’s condition requires. 

0246(2 times) – Health Services Deficiency for failure to ensure PRN medications administered by a qualified medication aide only upon authorization by a licensed nurse or physician.  The QMA must receive appropriate authorization for each administration of a PRN medication.  All contacts with a nurse or physician not on the premises for authorization to administer PRN’s shall be documented in the nursing notes indicating the time and date of the contact. 

0144(2 times) – Sanitation and Safety Standards Deficiency for failure of the facility to be clean, orderly, and in a state of good repair, both inside and out, and shall provide reasonable comfort for all residents. 

If you have questions or would like assistance in preparing for your annual survey, email ldavenport@ihca.org .