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Date ArticleType
3/29/2018 Regulatory
Residential Citation Update for February 2018

The Indiana State Board of Health conducted four surveys in the month of February. Of those, one (25%) were found to be deficiency free. There were a total of 43 residential tag citations with five of them being offense tags. The following are the offensive tags:

0241 (4 times) -- Health Services Offense for failure to ensure administration of medications and the provision of residential nursing care was as ordered by the resident’s physician and supervised by a licensed nurse on the premises or on call.

0406 (1 time) -- Infection Control for failure to establish and maintain an infection control practice designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of diseases and infection. 

The following are the residential citations for February:

0117 (6 times) -- Personnel Noncompliance for failure to ensure staff to be 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.  The number, qualification, and training of staff shall depend on skills required to provide for the specific needs of the residents.  A minimum of one (1) awake staff person, with current CPR and first aid certificates, shall be on site always. 

0273 (6 times) -- Food and Nutritional Services for failure to ensure that 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, including 410 IAC 7-24.

0217 (3) – Evaluation Deficiency for not ensuring that following completion of an evaluation, the facility using appropriately trained staff members, identified and documented the services to be provided by the facility.  Documentation of the services to be provided to include: scope, frequency, need; and preference of the resident.  The services offered are to be reviewed and revised as appropriate and discussed by the resident and facility as needs or desires change.  Either the facility or the resident can request a service plan review.  The agreed upon service plan is to be signed and dated by the resident, and a copy of the service plan shall be given to the resident upon request. 

036 (2 times) Residents’ Rights for failure of the facility to immediately consult 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. 

0298 (2times) – Pharmaceutical Services Deficiency for failure to ensure labeling of prescription drugs shall include the resident’s full name, physician’s name, prescription number, name and strength of drug, directions for use, date of issue and expiration date (when applicable), the name and address of the pharmacy.

0304(2times) Pharmaceutical Services Deficiency for failure to ensure medicine or treatment cabinets or rooms were appropriately locked always except when authorized personnel are present.  All scheduled II drugs administered by the facility shall be kept in individual containers under double lock and stored in a substantially constructed box, cabinet, or mobile drug storage unit. 

0414 (2 times) – Infection Control Deficiency for failure to ensure staff washed their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

0029 (1 time) – Residents’ Rights for failure to ensure residents are treated with consideration, respect, and recognition of their dignity and individuality.

0090 (1 time) – 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.  Notice of unusual occurrence may be made by telephone, followed by a written report, or by a written report only that is faxed or sent by electronic mail to the division within the twenty-four-hour time.               

0144 (1 time) – Sanitation and Safety Standards Deficiency for failure to ensure the facility is clean and orderly, and in a state of good repair, both inside and out, and shall provide reasonable comfort for all residents.

0148 (1 time) -- Sanitation and Safety Standards Deficiency for failure to maintain buildings, grounds and equipment in a clean condition, in good repair, and free of hazards that may adversely affect the health and welfare of the residents or the public as follows:  1) Each facility shall establish and implement a written program for maintenance to ensure the continued upkeep of the facility.  2) The electrical system, including appliances, cords, switches, alternate power sources, fire alarm and detection systems, shall be maintained to guarantee safe functioning and compliance with state electrical codes.

0156 (1 time) -- Sanitation and Safety Standards for failure of the facility’s food supplies to meet the standards of 410 IAC 7-24. 

0157 (1 time) – Sanitation and Safety Standards Deficiency for failure to adopt, and implement written policies and procedures on cleaning, disinfecting, and sterilizing equipment used by more than one (1) person in a common area. 

214 (1 time) – Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident was initiated prior to admission and updated at least annually 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.

0246 (1 time) – Health Services Deficiency for failure to ensure PRN medications were administered by a QMA only upon authorization by a licensed nurse or physician and documented appropriately. 

0248 (1 time) – Health Services Deficiency for failure to ensure to have available on the premises or on call the services of a licensed nurse always. 

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