Residential Citation Update – April 2021

There was a total of twenty-four (24) surveys performed by the IDOH during the month of April 2021, and of those, seven (7) or 29% were found to be deficiency free. A total of eighty (80) residential tags were cited with eleven (11) of those being Offense tags.

April Tag Citation’s by Subject Matter

• Resident’s Rights – 14 citations – 70% of providers receiving a citation in this area.
• Food & Nutritional – 14 citations – 70% of providers receiving a citation in this area.
• Health Services – 12 citations – 60% of providers receiving a citation in this area.
• Pharmaceutical – 9 citations – 45% of providers receiving a citation in this area.
• Sanitation & Safety – 8 citations – 40% of providers receiving a citation in this area.
• Infection Control – 7 citations – 35% of providers receiving a citation in this area.
• Personnel – 6 citations – 30% of providers receiving a citation in this area.

Offense Tags

• Tag 052 (7 times) – Residents’ Rights — Failure to ensure the right of residents to be free from abuse of any kind.
• Tag 241 (3 times) – Health Services – Failure to ensure the administration of medications and provision of residential nursing care is as ordered by the resident’s physician and supervised by a licensed nurse on the premises or on call.
• Tag 406 (1 time) – Infection Control – 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.

Top Residential Tag Citations

• Tag 273 (12 times) – Food and Nutritional Services Deficiency – Failure to ensure all food preparation and serving areas are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.
• Tag 117 (6 times) – Personnel Noncompliance – Failure to ensure staff in sufficient 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. A minimum of one (1) awake staff person, with current CPR and first aid certificates, shall be always 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 be always 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 240 (5 times) – Health services – Failure to ensure personal care, and assistance with activities of daily living, shall be provided based upon individual needs and preferences.
• Tag 414 (4 times) – Infection Control – Failure to ensure staff washed hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
• Tag 90 (3 times) – Administration and Management – 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.
• Tag 148 (3 times) – Sanitation and Safety Standards – 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 as follows: 1) Each facility to establish and implement a written program for maintenance to ensure the continued upkeep of the facility. 2) The electrical system, including appliances, cords, switches, alternative power sources, fire alarm and detection systems, shall be maintained to guarantee safe functioning and compliance with state electrical codes. 3) Plumbing shall function properly and comply with state plumbing codes. 4) At least yearly, heating, and ventilating systems to be inspected.
• Tag 217 (3 times) – Evaluation Deficiency – Failure to ensure that 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: the services offered shall be appropriate in scope, frequency, need and preference.  The services to be reviewed and revised as appropriate and discussed by the resident and facility as needs or desires change.  The service plan to be signed and dated by the resident and a copy given upon request to the resident.  A licensed nurse to be involved in identification and documentation of services provided to a resident when administration of medications or the provision of residential nursing services, or both is needed.
• Tag 298 (3 times) – Pharmaceutical Services – Failure to ensure a consultant pharmacist is employed, or under contract, and responsible for the duties as specified I 856 IAC 1-7; A) Review the drug handling and storage practices in the facility. B) Provide consultation on methods and procedures of ordering, storing, administering, and disposing of drugs as well as medication record keeping. C) Report, in writing, to the administrator or designees and any irregularities in dispensing or administration of drugs. D) Review the drug regimen of each resident receiving these services at lest once every sixty (60) days.
• Tag 301 (2 times) – Pharmaceutical Services – Failure to ensure labeling of prescription drugs 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 the medication is packaged in a unit dose, reasonable variations that comply with the acceptable pharmaceutical procedures are permitted.
• Tag 302 (2 times) – Pharmaceutical Services – Failure to ensure over-the-counter medications are identified with the following: A) Resident name. B) Physician name. C) Expiration date. D) Name of drug. E) Strength.

For assistance, questions, or to arrange a site visit to help you prepare for survey, email ldavenport@ihca.org