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Residential Citation Update for November, 2019 - IHCA

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Residential Citation Update for November, 2019

Posted Jan 13, 20203 min Read

Regulatory & Clinical

The Indiana State Department of Health conducted a total of 20 surveys in November and of those, two (10%) were found to be deficiency free.  There was a total of 11 Offense tags cited; 43 Deficiency tags for a total of 54 Residential tags cited for the month of November.

The 11 Offense tags are as follows: 

  • Tag 052 (6 times) – Resident’s Rights Offense for failure to ensure that residents right to be free from any abuse was upheld.
  • Tag 241 (4 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.
  • Tag 245 (1 time) – Health Services Offense for failure to ensure injectable medications are only administered by licensed staff.

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

  • Tag 273 (7 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 090 (5 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 246 (3 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 148 (3 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 155 (3 times) – Sanitation and Safety Standard Deficiency for not having an effective garbage and waste disposal program in accordance with 410 IAC 7-24. Provision shall be made for the safe and sanitary disposal of solid waste, including dressings needles, syringes, and similar items.
  • Tag 217 (3 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 414 (3 times) – Infection Control Deficiency for failure to ensure staff wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.
  • Tag 041 (2 times) – Residents’ Rights Deficiency for not having developed and implemented policies for investing and responding to complaints when made known and grievances made by: A) an individual resident; B) a resident council or family council, or both; C) a family member; D) family groups; or E) other individuals.
  • Tag 045 (2 times) – Residents’ Rights Deficiency for failure to ensure compliance before an interfacility transfer or discharge occurs.
  • 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 298 (2 times) – Pharmaceutical Services Deficiency to ensure a consultant pharmacist is employed, or under contract, and responsible for the duties as specified in 856 IAC 1-7.

 Please forward questions and/or requests for survey readiness to