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Residential Citation Update – May 2019

Posted Jul 1, 20192 min Read

Regulatory & Clinical

The Indiana State Department of Health conducted a total of eighteen recertification surveys and of those, six (33.33 %) were found to be deficiency-free.  There was a total of 11 Offense tags cited, 60 Deficiency tags cited for a total of 71 Residential tags for the month of May.

The Offense citations are as follows:

Tag 241 (8 times) – Health Services Offense for failure to ensure administration of medications and the provision of residential nursing care is as ordered by the physician and supervised by a licensed nurse on the premises or on call as follows:  (1) Medication to be administered  by licensed nursing personnel or qualified medication aides.

Tag 051 (1 time) – Resident Rights Offense for failure to ensure residents right to be free from:  sexual, physical, mental, for corporal punishment, neglect, and involuntary seclusion was upheld.

Tag 242 (1 time) – (1 time) – Health Services Offense for failure to ensure

Tag 406 (1 time) – (1 time) – Infection Control for 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.

The top Five Deficiency citations are as follows: 

Tag 273 (10 times) — Food and Nutritional Services Noncompliance for failure to ensure an organized food service department directed by a supervisor competent in food service management and knowledge in sanitation standards, food handling, food preparation and meal service.

Tag 117 (8 times) — Personnel Deficiency for failure to ensure staff are 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.

Tag 155 (4 times) — Sanitation and Safety Standards Deficiency for failure to ensure 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 (4 times) — Evaluation Deficiency for failure to ensure following completion of an evaluation, the facility, using appropriately trained staff members, identified and documented the services to be provided by the facility as follows:  1) The services offered to the individual resident are appropriate to scope, frequency, need and preference of the resident.

Tag 090 (3 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.

A deeper dive into the top tags and how to prevent getting them will be presented on July 12 at the Assisted Living Conference.  The building blocks of a successful survey will be presented during the pre-conference education on July 11.