Residential Citation Update

The Indiana Department of Health reported conducting the following survey activity in February:

• 22 Complaint Surveys
• 11 recertification Surveys
• 9 State Residential Surveys
• 1 Revisit Survey
• 2 Deficiency Free Surveys

There were seven (7) Offense Tags and sixty-four (64) Residential tags cited with two (2) deficiency free surveys.

The Offense Tags are as follows:

• Tag 052 (4 times) — Residents’ Rights Offense – Residents have the right to be free from 1) sexual abuse; 2) physical abuse 3) mental abuse; 4) corporal punishment; 5) neglect; and 6) involuntary seclusion.
• Tag 241 (2 times) – Health Services Offense – 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 as follows: 1) Medication shall be administered by licensed nursing personnel or qualified medications aides.
• Tag 245 (1 time) – Health Services Offense – Injectable medications shall be given only by licensed personnel.

Top Residential Tags are as follows:

• Tag 117 (8 times) – Personnel Deficiency – Staff shall be sufficient in number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hours scheduled and unscheduled needs of the residents and services provided. The number, qualifications, 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 always be on site. If fifty (50) or more residents of the facility regularly receive residential nursing services or administration of medication, or both, at least one (1) nursing staff person shall always be on site. Residential facilities with over one hundred (100) residents regularly receiving residential nursing services or administration of medication, or both, shall have at least one (1) additional nursing staff person always awake and on duty for every additional fifty (50) residents. Personnel shall be assigned only those duties for which they are trained to perform. Employee duties shall conform with written job descriptions.
• Tag 273 (8 times) – Food and Nutritional Services Deficiency – All food preparation and serving areas (excluding areas in resident units) are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.
• Tag 217 (5 times) – Evaluation Deficiency – Following completion of an evaluation; the facility, using appropriately trained staff members, shall identify and document the services to be provided by the facility, as follows; 1) The services offered to the individual resident shall be appropriate to the A) scope; B) frequency; C) need; and D) preference; of the resident. 2) The services offered shall be reviewed and revised as appropriate and discussed by the resident and facility as needs or desires change. Either the facility or the resident may request a service plan review. 3) The agreed upon service plan shall be signed and dated by the resident, and a copy of the service plan shall be given to the resident upon request. 4) No identification and documentation of services provided is needed if evaluations after the initial evaluation indicate no need for a change in services. 5) if administration of medications or the provision of residential nursing services, or both is needed, a licensed nurse shall be involved in identification and documentation of the services to be provided.
• Tag 090 (3 times) – Administration and Management Deficiency – The administrator is responsible for the overall management of the facility. The responsibilities of the administrator shall include, but are not limited to, the following: 1) Informing 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.
• Tag 214 (3 times) – Evaluation Deficiency – An evaluation of the individual needs of each resident shall be initiated prior to admission and shall be updated at least semiannually 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.