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Residential Citation Update, May 2024

Posted Jun 25, 20248 min Read

Regulatory & Clinical

The Indiana Department of Health reports the following survey activity for May 2024:  

  • 27 Complaint Investigations 
  • 9 Recertification Surveys 
  • 34 State Residential Surveys  
  • 1 Post Survey Revisit 

The IDOH reports the Residential Tag Report as follows:  

  • 13 Offense Tags  
  • 94 Deficiency Tags  
  • 107 Residential Tags Total  

Offense tags are as follows: 

Tag 052 (7 times) – Residents’ Rights Offense – Residents have 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 (4 times) – Health Services Offense – The administration of medications and the provision of residential nursing care shall be as ordered by the resident’s physician and sha be supervised by a licensed nurse on the premises or on call as follows: Medication shall be administered by licensed nursing personnel or qualified medication aides.  

Tag 242 (1 time) – Health Services Offense – The resident shall be observed for effects of medications. Documentation of any undesirable effects shall be contained in the medical record. The physician shall be notified immediately if undesirable effects occur, and such notification shall be documented in the clinical record.  

Tag 406 (1 time) – Infection Control Offense – The facility must 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 disease and infection.  

Top Residential Deficiency tags as follows:   

Tag 273 (23 times) – Food and Nutritional Services Deficiency – All food preparation and serving areas are maintained in accordance with state and local sanitation and safe food handling standards, including 410IAC 7-24.   

Tag 117 (11 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 217 (7 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 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 300 (5) times) – Pharmaceutical Services Deficiency – Over-the-counter medications, prescription drugs, and biologicals used in the facility must be labeled in accordance with currently accepted professional principals and included in appropriate accessory and cautionary instructions and the expiration date.  

Tag 090 (4 times) – Administration and Management Deficiency — The administrator is responsible for the overall management of 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. 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 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’s 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 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.  

Tag 118 (4 times) – Personnel Deficiency — Any unlicensed employee providing more than limited assistance with the activities of daily living must be either a certified nurse aide or a home health aide. Existing facilities that are not licensed on the date of adoption of this rule and that seek licensure within one (1) year of adoption of this rule have two (2) months in which to ensure that all employees in this category are either a certified nurse aide or a home health aide.  

Tag 246 (4 times) – Health Services Deficiency — PRN medications may be 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 PRNs shall be documented in the nursing notes indicating the time and date of the contact. 

Tag 247 (4 times) – Health Services Deficiency – Any error in medication administration shall be noted in the resident’s record. The physician shall be notified of any error in medication administration when there are any actual or potential detrimental effects to the resident. 

Tag 148 (3 times) – Sanitation and Safety Standards Deficiency — The facility shall 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 shall establish and implement a written program for maintenance to ensure the continued upkeep of the facility. (2) The electrical system, including appliances, cords, switches, alternate power sources, fire alarm and detection systems, shall be maintained to guarantee safe functioning and compliance with state electrical codes. (3) All plumbing shall function properly and comply with state plumbing  

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.  

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