Residential Citation Update: July

The Indiana Department of Health reported the following survey activity for the month of July in Licensed Residential Facilities:  

• Complaint Investigations – 25                

• Recertification Survey – 6 

• State Residential Survey – 18  

• Deficiency Free – 8  

There were sixty-seven (67) Residential Tags cited, of which six were Offense Tags.  

The Offense Tags are as follows:  

• Tag 52 (4 times) – Residents’ Rights Offense – Residents have the right to be free from: 1) sexual abuse; 2) physical abuse: #) 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 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.  

Top Residential Deficiency Tags are as follows:  

Tag 273 (12 times) – Food and Nutritional Services Deficiency  

• All food preparation and serving areas (excluding areas in residents’ units are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.  

Tag 217 (10 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 services 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 117 (7 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 depend on skills required to provide for the residents’ specific needs. 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 154 (5 times) – Sanitation and Safety Standards – Deficiency 

• The facility shall keep all kitchens, kitchen areas, common dining areas, equipment, and utensils clean, and free from litter and rubbish, and maintained in good repair in accordance with 410 IAC 7-24.  

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.  

Tag 090 (3 times) – Administration and Management Deficiency  

The administrator is responsible for managing 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.  
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 representative.  
3. Obtaining director approval before 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 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, and 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 survey reports conducted by the division in each facility for two (2) years and making them available for inspection to any member of the public upon request.