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Date ArticleType
4/30/2018 Regulatory
Residential Citation Update for March Surveys

The Indiana State Board of Health conducted ten surveys in the month of March. Of those, four (40%) were found to be deficiency free. There was a total of thirty-nine residential tag citations with four of them being offense tags. Mental Health Screening and Activities Program Tags cited for the first time this year. The following are the offensive tags:

0052(1 time) –  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.

0241(2 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. 

0242 (1 time) – Health Services Offense for failure to observe for effects of medications.  Failure to ensure documentation of undesirable effects was contained in the clinical record and failure to document physician notification of those undesirable effects. 

The following are the residential tags cited for the month of March:
0273 (7 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.

0240 (3 times) – Health Services Deficiency for failure to ensure personal care, and assistance with activities with activities of daily living were provided based upon individual needs.

0254 (2 times) – Residents’ Rights Deficiency for failure to ensure the right to confidentiality of all personal and clinical records. Information from these sources are not to be released without consent unless the resident is transferred to another health facility, when required by law, or under a third-party payment contract.  The resident’s records shall be made immediately available to the resident for inspection, and the resident may receive a copy within five (5) working days, at the resident expense. 

0117 (2 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 aid certificates, were on site always. 

The following tags were cited one time:
0036 – Residents’ Refights Deficiency for failure to immediately consult the resident’s physician and the resident’s legal representative when the facility noticed: 1) a significant decline in 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. 

0045 – Residents’ Rights Deficiency for failure to follow the regulations related to transfer and discharge from the facility. 

0090 – 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. 

0148 – 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.

0152 – Sanitation and Safety Standards Deficiency for failure to handle, store, process, and transport clean and soiled linen in a safe and sanitary manner that prevents the spread of infection. 

0156 – Sanitation and Safety Standards Deficiency for failure to ensure the facility food supplies meet the standards of 410 IAC 7-24.

0187 –Physical Plant Standards Deficiency for failure to ensure hot water temperature for all bathing and hand washing facilities are controlled by an automatic control valve.  Water temperature at the point of use must be maintained between one hundred (100) degrees Fahrenheit and one hundred twenty (120) degrees Fahrenheit. 

0214 – Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident is initiated prior to admission and updated at least semiannually and upon a known substantial change in condition. 

0217 – Evaluation Deficiency for failure to identify and document the services to be provided by the facility in detail.

0246 – Health Services Deficiency for failure to ensure QMA’s obtain authorization from a licensed nurse or physician, prior to administering PRN medications and documented in the resident record.

0247 – Health Services Deficiency – failure to ensure any error in medication administration is documented in the resident record and the physician is notified including when there are actual or potential detrimental effects to the resident.

0248 –Health Services Deficiency – failure to have available on the premises or on call the services of a licensed nurse always. 

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

0298 – Pharmaceutical Services Deficiency for failure to ensure a consultant pharmacist is employed or under written contract and responsible for the duties specified in 856 IAC 1-7.

0302 – Pharmaceutical Services Deficiency for failure to ensure over-the-counter medications are identified with resident name, physician name, expiration date, name of the drug, strength.

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

0326 –Activities Program Deficiency for failure to provide activities programs appropriate to the abilities and interest of the residents being served. 

379 -- Mental Health Screening Deficiency – If a person is a recipient of Medicaid or federal SSI and has a major mental illness as defined by the individual needs assessment, the person will be referred to the mental health service provider for a consultation on needed treatment services.  All persons admitted after April 1, 1997, shall have the assessment completed prior to the admission, and if a mental health center consultation is needed, the consultation shall be completed prior to the admission and a copy maintained in the clinical record. 

0383 – Mental Health Screening Deficiency – The residential care facility, in cooperation with the; mental health service providers, shall develop the comprehensive care plan.

0414 – Infection Control for failure of the facility to require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. 

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