The Indiana State Department of Health conducted a total of twelve recertification surveys and of those, five (50%) were found to be deficiency free. There was a total of 14 Offense tags cited, 72 Deficiency tags cited for a total of 86 Residential tags cited for the month of July.
The Offensive tags cited are as follows:
Tag 052 (3 times) – Residents’ Rights Offense for failure to ensure the right of each resident to be free from abuse of any kind.
Tag 241 (5 times) – Health Services Offense for failure to ensure the administration of medications and the provision of residential nursing care is as ordered by the physician and supervised by a licensed nurse on the premises.
Tag 242 (1 time) – Health Services Offense for failure to ensure residents are observed for effects of medications and document undesirable effects in the medical record. The physician to be notified immediately if undesirable effects occur, and such notification documented in the medical record.
Tag 245 (1 time) – Health Services Offense for failure to ensure injectable medications to be administered only by a licensed nurse.
Tag 406 (4 time) – Infection Control Offense 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 top Residential tags are as follows:
Tag 273 (8 times) – Food and Nutritional Services for failure to ensure all food preparation and services areas are maintained in accordance with state and local sanitation and safe food handling standards.
Tag 148 (6 times) – Sanitation and Safety Standards for failure to maintain buildings, grounds, and equipment in a clean condition, in good repair, and free from hazards that may adversely affect the health and welfare of the residents or public.
Tag 246 (6 times) – Health Services Deficiency for failure to ensure PRN medications administered by a QMA only after authorization by a licensed nurse or physician and authorization documented each time for each administration.
Tag 117 (5 times) – Personnel Deficiency for failure to ensure staffing was adequate as well as training and qualifications. A minimum of one awake staff person, with a current CPR and first aid certificate.
Tag 214 (5 times) – Evaluation Deficiency for failure to an evaluation of the individual needs was initiated prior to admission and updated semiannually and upon a known substantial change in the resident’s condition.
Tag 217 (5 times) – Evaluation Deficiency for failure to document all required data once an evaluation was completed. The evaluation to be completed appropriately trained staff.
Tag 301 (4 times) – Pharmaceutical Services for failure to ensure proper labeling of prescription drugs.
Tag 304 (3 times) – Pharmaceutical Services Deficiency for failure to ensure medication or treatment cabinets or rooms were always appropriately locked except when authorized personnel are present.
Tag 090 (3 times) – Administration and Management Deficiency for failure to inform the division within twenty-four hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident.
Please direct your questions to ldavenport@ihca.org
If you would like to have assistance in preparing for your annual recertification survey, contact tharvey@ihca.org