Top 10 Health and LSC Deficiencies Cited in FY 2018

 

THCA has received from HHSC the Top 10 cited deficiencies for nursing facilities for fiscal year 2018.  The list includes:

  • Top 10 Deficiencies Cited During Inspections for FY 2018: Nursing Facilities – Health
  • Top 10 Deficiencies Cited During Inspections for FY 2018: Nursing Facilities – Life Safety Code

 

Top 10 Deficiencies Cited During Inspections for FY 2018

Nursing Facilities – Health

  1. Infection Prevention and Control: 42 CFR 483.80(a)(1)(2)(4)(e)(f), TAG 0880 – The facility failed to comply with requirements related to an infection prevention and control
  2. Food Procure, Store/Prepare/Serve – Sanitary: 42 CFR 60(i)(1)(2), TAG 0812 – The facility failed to comply with certain requirements related to food sources, storage, and safe handling.
  3. Develop/Implement Comprehensive Care Plan: 42 CFR 21(b)(1), TAG 0656 – The facility failed to comply with certain requirements related to the development and implementation of a person-centered care plan.
  4. Pharmacy Services/Procedures/Pharmacist/Records: 42 CFR 45(a)(b)(1)-(3), TAG 0755 – The facility failed to comply with requirements related to the provision of pharmaceutical services.
  5. Free of Accident Hazards/Supervision/Devices: 42 CFR 25(d)(1)(2), TAG 0689 – The facility failed to comply with accident prevention requirements.
  6. Bowel/Bladder Incontinence, Catheter, UTI: 42 CFR 25(e)(1)-(3), TAG 0690 – The facility failed to comply with requirements related to bowel and bladder incontinence.
  7. ADL Care Provided for Dependent Residents: 42 CFR 483.24(a)(2), TAG 0677 – The facility failed to comply with requirements for providing assistance with daily living care for dependent
  8. Competent Nursing Staff: 42 CFR 483.35(a)(3)(4)(c), TAG 0726 – The facility failed to comply with certain requirements related to the proficiency and competency of the nursing
  9. Resident Records- Identifiable Information: 42 CFR 20(f)(5); 483.70(i)(1)-(5), TAG 0842 – The facility failed to comply with resident- identifiable information and medical records requirements.
  • Develop/Implement Abuse/Neglect Policies: 42 CFR 12(b)(1)-(3), TAG 0607 – The facility failed to comply with requirements related to the development and implementation of written policies and procedures on abuse, neglect, and exploitation of residents and misappropriation of resident property.

 

Top 10 Deficiencies Cited During Inspections for FY 2018

Nursing Facilities – Life Safety Code

A new federal regulation set for Life Safety Code in this facility type went into effect January 22, 2018. FY 2017 rankings will not be available for these new tags.

 

  1. Heating Ventilation and Air Conditioning: National Fire Protection Association (NFPA) 101, TAG 0521 – The facility failed to comply with Life Safety Code requirements for heating, ventilation, and air conditioning (Ranked No. 1 in FY 2017)
  2. Sprinkler System – Maintenance and Testing: NFPA 101, TAG 0353 – The facility failed to comply with requirements for testing, maintaining, and inspecting a sprinkler system or for retaining records related to the sprinkler system. (Ranked No. 3 in FY 2017)
  3. Subdivision of Building Spaces – Smoke Barrier Construction: NFPA 101, TAG 0372 – The facility failed to construct smoke barriers in accordance to certain Life Safety Code requirements or with the required resistance (Ranked No. 2 in FY 2017)
  4. Means of Egress – General: NFPA 101, TAG 0211 – The facility failed to comply with requirements for egress, including aisles, passageways, corridors, exit discharges, or exit locations. (Ranked No. 5 in FY 2017)
  5. Hazardous Areas – Enclosure: NFPA 101, TAG 0321 – The facility failed to comply with requirements related to the protection of hazardous areas. (Ranked No. 4 in FY 2017)
  6. Electrical Systems – Essential Electrical System Maintenance and Testing: NFPA 101, TAG 0918 – The facility failed to test and maintain the generator or alternate power source as required by the Health Care Facilities Code. (Ranked No. 9 in FY 2017)
  7. Corridor – Doors: NFPA 101, TAG 0363 – The facility failed to comply with requirements related to corridor doors, including door construction and fire rating, means for keeping doors closed, clearance beneath doors, impediments to closure of doors, use of roller latches, or construction and labeling of door frames. (Tied for No. 7 in FY 2017)
  8. Cooking Facilities: NFPA 101, TAG 0324 – The facility failed to comply with requirements related to cooking facilities or cooking equipment. (Tied for No. 7 in FY 2017)
  9. Utilities – Gas and Electric: NFPA 101, TAG 0511 – The facility failed to comply with the National Fuel Gas Code or the National Electric Code related to equipment using gas or related gas piping. (Ranked No. 10 in FY 2017)
  10. Egress Doors: NFPA 101, TAG 0222 – The facility failed to comply with requirements for latches, locks, or special locking arrangements on egress doors. (Not ranked in FY 2017)