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Licensure, Survey and Certification

Helping our members stay compliant

The regulatory and survey landscape for our members comes with many challenges, especially with the changing needs of residents, new/changed regulatory requirements, workforce demands, and increasing resident acuity.  

How We Help

  • We work closely with our member providers across the state to help them stay laser-focused on delivering high quality care to Indiana’s seniors every single day.
  • We strive to equip our members with powerful tools and resources, so they stay up to date with industry trends and best practices and have the needed knowledge base to comply with regulatory requirements.
  • By creating awareness through education in both skilled nursing and assisted living facilities, we enhance our members’ understanding of the current citation trends, so they are better prepared to proactively assess and monitor facility performance.

Consultation Areas

Our members have access to one-on-one consultation customized to meet their needs.

Assistance with State Licensure

We can provide immediate intervention during a survey or provide answers to your questions.

Federal Requirements of Participation

We can keep you on track with demanding deadlines and provide solutions and education to keep your team on track and mitigate regulatory concerns.

Life Safety Code and Emergency Preparedness

We can provide survey guidance and resources to help you mitigate regulatory risks.

Payroll Based Journal

We can help you understand flags leading to an audit or help you understand and respond to your audit.

Focus F-Tag of the Week

Each week through October, our national affiliate, American Health Care Association’s regulatory and clinical affairs team will be focusing on a particular F-tag(s) to help long-term care providers like you break down the Phase 2 updates and Phase 3 new guidance.

§483.90-Physical Environment – F919-Resident Call System

CMS made changes to §483.90(g)(1)‐(2) Resident Call System. The regulation states the facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident’s bedside and toilet and bathing facilities.

The guidance outlines that the call system must be accessible to residents while in their bed or other sleeping accommodations within the resident’s room. In addition, the call system must be accessible to the resident at each toilet, bath, or shower and should be accessible to a resident lying on the floor.

Action for Facilities:  

  • Develop a process to routinely ensure the call system for residents is operational.
  • Review the process to ensure that during a loss of power, the resident call system will be operational or ensure there is an alternate means of communicating with the staff in place.
  • Examine the functionality of the call system to ensure it is accessible to a resident lying on the floor.

Detailed information can be found in the Appendix PP-State Operations Manual.

§483.45-Pharmacy Services

CMS has revised the §483.45-Pharmacy Services guidance. Changes include the following:

  • F755-Pharmacy Services: CMS provided clarification language related to the disposal of Fentanyl patches.
  • F757-Drug Regimen is Free from Unnecessary Drugs: CMS added language related to antibiotic stewardship and F881.
  • F758-Free from Unnecessary Psychotropic Medications/PRN Use: CMS provided clarification of other classes of drugs not listed in the regulation and how they are affected by the psychotropic medication requirements. CMS also added language on potential misdiagnoses, such as schizophrenia, in order to prescribe antipsychotics.

Detailed information can be found in the Appendix PP-State Operations Manual.

Access the full summary

§483.85 Compliance and Ethics – F895

Under §483.85, facilities must have a comprehensive Compliance and Ethics (C&E) program meeting all requirements laid out by CMS. Surveyors will be reviewing the facilities’ written policies and procedures and interviewing both staff and high-level personnel overseeing the program to determine if this program is in place. They will look for examples of the compliance program in action, evidence of the annual review, and that the organization has completed due diligence on the high level personnel overseeing the program.


Staying Compliant Through QAPI

IHCA/INCAL uses QA+PI=QAPI comprehensive approach in analysis of the most current survey trends and provides education to our members in live education, webinars and notification of up to date changes in regulation to ensure our members are able to: 

  • Identify opportunities for improvements
  • Collaborate to resolve and find solutions
  • Address gaps in systems or processes 
  • Develop and implement a proactive approach to care and/or a corrective plan
  • Continuously monitor effectiveness of interventions.

Improving Compliance and Residential Care

Whether you operate a skilled nursing facility or an assisted living community, IHCA/INCAL provides information and services aimed at improving compliance and residential care.

Clinical Systems & Programs

Assistance with Quality Assurance Performance Improvement (QAPI), memory care, infection control, preventable readmissions, and more.

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Member Services

Access on-site and telephonic assistance with survey readiness, plan of correction and IDR guidance, and custom training & presentations.

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