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Residential Citation Update for January 2020 Survey Activity

Posted Mar 10, 20207 min Read

Regulatory & Clinical

The top survey tag in the residential setting is Tag 273 and was cited in 16 out of the 18 surveys conducted in January 2020. This tag can be avoided with focus and education to food service culinary staff.  If you are in your survey window, schedule an onsite visit to assist with survey readiness in your kitchen by emailing

The Indiana State Department of Health conducted a total of 18 surveys in the month of January 2020 and of those, 3 (16.67%) were found to be deficiency free. There were total of 9 Offense tags cited; 71 Deficiency tags for a total of 80 Residential tags cited for the month of January.

The Offensive tag citations are as follows:

Tag 052 (7 times) – Residents’ Rights Offense for failure to ensure 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 for failure to ensure 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 medication aides.

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

Tag 273 (16 times) – Food and Nutritional Services Deficiency for failure to ensure 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 090 (7 times) – Administration Management Deficiency for failure to ensure 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. Notice of unusual occurrence may be made by telephone, followed by a written report, or by a written report only that is faxed or sent by electronic mail to the division within the twenty-four (24) hour time period. Unusual occurrences include, but are not limited to:

(A) epidemic outbreaks.

(B) poisonings.

(C) fires; or

(D) major accidents.

If the division cannot be reached, a call shall be made to the emergency telephone number published by the division.

(2) Promptly arranging for or assisting with the provision of medical, dental, podiatry, or nursing care or other health care services as requested by the resident or

resident’s legal representative.

(3) Obtaining director approval prior to the admission of an individual under eighteen (18) years of age to an adult facility.

(4) Ensuring the facility maintains, on the premises, an accurate record of actual time worked that indicates the:

(A) employee’s full name; and

(B) dates and hours worked during the past twelve (12) months.

(5) Posting the results of the most recent annual survey of the facility conducted by state surveyors, any plan of correction in effect with respect to the facility, and any subsequent surveys. The results must be available for examination in the facility in a place readily accessible to residents and a notice posted of their availability.

(6) Maintaining reports of surveys conducted by the division in each facility for a period of two (2) years and making the reports available for inspection to any member of the public upon request.

Tag 117 (5 times) – Personnel Deficiency for failure to ensure Staff enough in 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. The number, qualifications, and training of staff shall depend on skills required to provide for the specific needs of the residents.

Tag 214 (4 times) – Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident is initiated prior to admission and 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.

Tag 217 (4 times) – Evaluation Deficiency for failure to ensure the services offered to the individual resident are 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 240 (3 times) – Health Services Deficiency for failure to ensure personal care, assistance with activities of daily living, is provided based upon individual needs and preferences.

Tag 272 (3 times) – Food Nutritional Food Services Deficiency for failure to ensure all food is served at a safe and appropriate temperature.

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

Tag 144 (2 times) – Sanitation and Safety Standards Deficiency for failure to ensure that the facility is clean, orderly, and in a state of good repair, both inside and out, provides reasonable comfort for all residents.

Tag 035 (2 times) – Residents’ Rights Deficiency for failure to ensure residents have the rights to the following:  1) Participate in the development of his or her service plan and in any updates of the service plan.  2) Choose attending physician of choice and other service providers. Any limitation on the resident’s right to choose the attending physician or service provider, or both, will be clearly stated in the admission agreement.  3)  Have a pet of choice, so long as the pet does not pose a health or safety risk to residents, staff, or visitors or a risk to property unless prohibited by the facility policy.  Any limitation will be outlined in facility admission agreement.  4)  Refuse treatment or medications.  5)  Be informed of the medical consequences of refusal of treatment and or medications.  6) Confidentiality of treatment.  7) Participate or refuse to participate in experimental research.

Tag 414 (2 times) – Infection Control Deficiency for failure to require staff to wash hands after each resident contact requiring it by acceptable professional standards of practice.

Tag 154 (2 times) – Sanitation and Safety Standards for failure to keep 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 155 (2 times) – Sanitation and Safety for failure to have an effective garbage and waste disposal program in accordance with 410 IAC 7-24.  Provision made for the safe and sanitary disposal of solid waste, including dressings, needles, syringes, and similar items.

Tag 246 (2 times) – Health Services Deficiency for failure to ensure PRN medication 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 physician not on the premises for authorization to administer PRN’s are to be documented in the nursing notes indicating the time and date of the contact.

Tag 247 (2 times) – Health Services Deficiency for failure to ensure any error in medication administration is noted in the resident’s record.  The physician notified of the error in medication administration when there are any actual or potential detrimental effects to the resident

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