The Indiana State Department of Health conducted a total of seven recertification surveys and of those, three (42.86%) were found to be deficiency-free. There was a total of eight Offense tags cited, 42 Deficiency tags cited for a total of fifty residential tags for the month of February.
The following Offensive tags were cited:
Tag 0052 (5 times) – Resident Rights Offense for failure to ensure the resident right to be free from any physical or chemical restraints ‘s for purposes of discipline or convenience and not required to treat the resident’s medical condition was upheld.
Tag 0241 (2 times) – Health Services Offense for failure to ensure the administration of medications and the provision of residential nursing care was as ordered by the physician and supervised by a licensed nurse on the premises or on call as follows: (1) Medications shall be administered by licensed nursing personnel or qualified medication aides.
Tag 0051 (1 times) – 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.
The following residential tags were cited:
Tag 273 (4 times) – Food and Nutritional Services
Tag 117 (3 times) – Personnel Deficiency
Tag 144 (3 times) – Sanitation and Safety Standards
Tag 240 (3 times) – Health Services Deficiency
Tag 246 (3 times) – Health Services Deficiency
Tag 148 (2 times) – Sanitation and Safety Standards
Tag 154 (2 times) – Sanitation and Safety Standards
Tag 214 (2 times) – Evaluation Deficiency
Tag 217 (2 times) – Evaluation Deficiency
Tag 302 (2 times) – Pharmaceutical Deficiency
There were several single tag citations for the following:
Tag 0029, 0041, 0045, 0090, 0187, 0215, 0270, 0272, 0275, 0378, and 0414.
The focus this month are tags 378 & 379 — Mental Health Screening Deficiency Tags. There has been a gradual uptick in surveys resulting in one or both tags being cited during surveys over the last 6 months.
Tag 0378 – Mental Health Screening – 410 IAC 16.2-5-11.1(b)(1-3) – If the individual is a recipient of Medicaid or federal Supplemental Income (SSI), the individual needs evaluation provided in section 2 (a) of this rule shall include the following: (1) Screening of the individual for major mental illness, such as diagnosed major mental illness, is limited to the following disorders: Schizophrenia, Schizophrenia disorder, Mood (bipolar and major depressive type) disorder, Paranoid or delusional disorder, Panic or other severe anxiety disorder, Somatoform or paranoid disorder, Personality disorder, Atypical psychosis or other psychotic disorder.
Tag 0379 – If a person is a recipient of Medicaid or federal SSI and has a major mental illness as defined by the individual need’s assessment, the person will be referred to the mental health services provider for a consolation on needed treatment services. Each provider to ensure the following to prevent this citation:
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All persons admitted after April 1, 1997 will have the assessment completed prior to admission
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If a mental health center consultation is needed, the consultation will be completed prior to the admission.
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A copy of assessments and or consultation will be maintained in the clinical record.
If you have questions or need assistance, email ldavenport@ihca.org.