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Date ArticleType
2/9/2020 Regulatory
Residential Update for December 2019

The Indiana State Department of Health conducted a total of 16 surveys in December and of those, five (31.25%) were found to be deficiency free. There were a total of 6 Offense tags cited; 62 Deficiency tags for a total of 68 Residential tags cited for the month of December. 

The 6 Offense tags are as follows: 

Tag 052 (3 times) – Resident’s Rights Offense for failure to ensure that residents right to be free from any abuse was upheld. 

Tag 241 (3 times) – Health Services Offense for failure to ensure the administration of medications and provision of residential nursing care is delivered as ordered by the physician and supervised by a licensed nurse on the premises or on call. 

The top Residential Tags that are not Offensive Tags are as follows:

Tag 273 (12 times) – Food and Nutritional Services Deficiency for failure to all food preparation and serving areas are maintained in accordance with state and local sanitation and safe food handling standards.  Listed in 410 IAC 7-24.

Tag 117 (9 Times) – Personnel Deficiency for failure to ensure staff were enough in number, qualifications, and training to meet the scheduled and unscheduled needs of the resident and services provided twenty-four (24) hours daily.

Tag 217 (5 times) – Evaluation Deficiency for not ensuring that after an evaluation, the facility, using appropriately trained staff members, shall identify and document the services to be provided by the facility. (scope, frequency, need and preference of the resident)

Tag 246 (4 times) – Health Services Deficiency for failure to ensure PRN medications are administered by a qualified medication aide (QMA) 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 a physician not on the premises for authorization to be documented in the nursing notes indicating the time and ate of the contact. 

Tag 247 (3 times) – Health Services Deficiency for failure to ensure any errors in medication administration are noted in the resident record and the resident’s physician was notified of medication administration error when actual or potential detriments are present to the resident.

Tag 301 (3 times) – Pharmaceutical Services Deficiency for failure to ensure 

Labeling of prescription drugs shall include the following: (A) Resident ' s full name. (B) Physician ' s name. (C) Prescription number. (D) Name and strength of the drug. (E) Directions for use. (F) Date of issue and expiration date (when applicable). (G) Name and address of the pharmacy that filled the prescription. If medication is packaged in a unit dose, reasonable variations that comply with the acceptable pharmaceutical procedures are permitted.

Tag 302 (2 times) – Pharmaceutical Services deficiency for failure to ensure Over-the-counter medications must be identified with the following: (A) Resident name. (B) Physician name. (C) Expiration date. (D) Name of drug. (E) Strength.

Tag 414 (2 times) – Infection Control Deficiency for failure to require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Tag 036 (2 times) – Residents’ Rights Deficiency for failure 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.

Tag 090 (2 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. Unusual occurrences include but are not limited to epidemic outbreaks; poisonings; fires; or major accidents.

Tag 118 (2 times) – Personnel Deficiency for failure to ensure any unlicensed employees providing more than limited assistance with activities of daily living must be either a certified nurse aide or a home health aide.

Tag 148 (2 times) -- Sanitation and Safety Standards Deficiency for not maintain buildings, grounds, and equipment in a clean condition, in good repair, and free of hazards that may affect the health and welfare of the residents or the public.

Tag 154 (2 times) -- Sanitation and Safety Standards - Deficiency for failure to keep all kitchens, kitchen areas, common dining areas, equipment, and utensils clean, free from litter and rubbish, and maintained in good repair in accordance with 410 IAC 7-24.

Tag 300 (2 times) -- Pharmaceutical Services - Deficiency for failure to ensure Over-the-counter medications, prescription drugs, and biologicals used in the facility must be labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date.

Please forward questions to ldavenport@ihca.org

As a member, IHCA/INCAL provides assistance in preparing your facility for survey compliance. Forward requests to ldavenport@ihca.org