10 MOST FREQUENTLY CITED VIOLATIONS Day Activity and Health Services Facilities* July 2015 *Adult Day Care Facilities name will be changed to Day Activity.
Download ReportTranscript 10 MOST FREQUENTLY CITED VIOLATIONS Day Activity and Health Services Facilities* July 2015 *Adult Day Care Facilities name will be changed to Day Activity.
Slide 1
10 MOST FREQUENTLY
CITED VIOLATIONS
Day Activity and Health Services Facilities*
July 2015
*Adult Day Care Facilities name will be changed to Day Activity and Health
Services Facilities effective 09-01-15
Slide 2
Welcome
This computer based training (CBT) was designed to
inform you about the 10 most frequently cited violations in
Day Activity and Health Services Facilities for the Fiscal
Year 2014.
Navigation
Click anywhere in the screen to go forward one slide at a
time.
Scroll up to go back.
Click the exit button in the top right hand corner to leave
the program.
Slide 3
Inspection Process
Inspectors base their decisions on the regulations from the following
documents:
•
•
•
•
Texas Administrative Code, Title 40, Part 1, Chapter 98: Adult Day
Care and Day Activity and Health Services Requirements;
Texas Human Resource Code, Title 6, Services for the
Elderly Chapter 103: Adult Day Care;
Texas Health and Safety, Title 4, Chapter 253: Employee
Misconduct Registry;
Texas Health and Safety Code, Title 4, Chapter 250: Nurse Aide
Registry and Criminal History Checks of Employees and
Applicants for Employment in Certain Facilities of Employees
and Applicants for Employment in Certain Facilities Serving Elderly
Persons with Disabilities.
Slide 4
State Rules
The Texas Administrative Code (TAC) chapter 98 contains
the state licensure rules governing DAHS that are enacted
under the authority of the Health Safety Code (HSC)
chapter 247.
Inspectors use the rules in Chapter 98 to determine
whether the facility is in compliance. Citations are based
on noncompliance with the standards.
Slide 5
Inspection Focus
DADS inspects DAHS to determine compliance with
minimum standards.
The inspection team may be just one person.
The inspection process is intended to:
• protect the health and safety and rights of clients; and
• determine compliance with regulations.
Slide 6
Inspection Focus
Violations can include both actual and potential negative
outcomes.
Inspectors determine whether the facilities are in
compliance during the inspection.
Slide 7
Inspection Focus
During the inspection, inspectors assess the facility’s:
• Compliance with clients’ rights requirements;
• Compliance with clients’ quality of life requirements;
• Compliance with clients’ quality of care requirements;
• Accuracy of clients’ comprehensive assessments;
• Adequacy of individualized care plans based on
comprehensive assessments; and
• Effectiveness of the physical environment to empower
clients, accommodate their needs and maintain safety.
Slide 8
DADS Annual Report
DADS is required to compile and report inspection and
enforcement data every year. This data is captured in the
Regulatory Services Annual Report.
Part of this report includes the top 10 violations cited during
the fiscal year covered in the report.
DADS Annual Report is available online at:
http://www.dads.state.tx.us/providers/reports/sb190/index.h
tml
Slide 9
DADS Annual Report
This presentation is based on the data contained in the
Regulatory Services FY14 Annual Report which covers the
period of 9/1/13 to 8/31/14.
Other than minor changes in position within the top 10, eight of
the top 10 violations listed in the FY13 annual report continue to
be top 10 issues in FY14.
The top 10 violations in the FY14 annual report are listed in
order from least frequently cited (#10) to most frequently cited
(#1).
Note: The violations in this presentation are just a summary of
violations (they are not complete violations).
Slide 10
Learning Objectives
In this course, you will:
• identify the 10 most frequently cited violations; and
• evaluate examples of the most frequently cited violations.
Slide 11
Violations Chart for FY14 and FY13
Rank
Tag Number
Tag Title
FY14
FY13
§98.62(d)(1)(A-H)
Staff Responsibilities/Director:
10
tied for 7th
§98.62(a)(1)(A)(B)
Staff Qualifications/Director
10
tied for 6th
§98.42(c)(1)(G)(iv)
Personal Safety/Fire-Smoking Regulations
9
not ranked
§98.61(b)(3)(A)
General: Employment Prohibition
8
not ranked
§98.61(b)(2)
General: HSC Chapter 250 Compliance
7
tied for 8th
§98.43(a)(7)
Sanitation/General−Odors/Refuse/Hazards
6
10
§98.64(c)(1)-(5)
Emergency Preparedness and Response/Plan
5
4
§98.62(d)(2)(A-H)
Staff Responsibilities/Nurse
4
3
§98.42(c)(1)(G)(iii)
Personal Safety/Fire-Smoking Regulations
3
5
§98.62(c)
Communicable Diseases/Staff Health
2
2
§98.43(b)(1)
Sanitation/Kitchen−Food Service Sanitation
1
1
Slide 12
#10: A206
§98.62(d)(1)(A-H) Staff Responsibilities/Director
(1) Facility director. The facility director is responsible for:
(A) managing the adult day care program and/or the facility;
(B) training and supervising facility staff;
(C) monitoring the facility building and grounds to ensure compliance;
(D) maintaining all financial and client records;
(E) developing relationships with community groups and agencies for
identification and referral of clients;
(F) maintaining communication with the client's family members or
responsible parties;
(G) assuring the development and maintenance of the individual plan of
care; and
(H) ensuring that, if he/she serves as the nurse consultant during the same
eight- hours-per-day period, he/she is fulfilling his/her responsibility as
director.
This tag was tied for number 7 in FY13.
Slide 13
#10: A206
§98.62(d)(1)(A-H) Staff Responsibilities/Director
The facility must ensure the director fulfills the responsibilities of the
position.
Examples of conditions cited might include not having systems in place
for:
• training and supervising facility staff;
• developing relationships with community groups and
agencies for referral of clients;
• communicating with the client's family members or
responsible parties; and
• developing and maintaining individual plans of care.
Slide 14
#10: A206 Example of a Citation
§98.62(d)(1)(A-H) Staff Responsibilities/Director
Based on record reviews and interview, the facility’s
director failed to ensure the development and maintenance
of the Health Assessment/Individual Plan of Care (HAIPC)
for three clients (#s 1,4 and 5) of five clients whose records
were reviewed.
The findings were:
• #1’s care plan had not been completed
• #4's plan of care was incomplete
• #5’s plan of care was incomplete
Clients #s 1, 4 and 5 enrolled in the facility during the last
six months.
Slide 15
#10: A206 (continued)
§98.62(d)(1)(A-H) Staff Responsibilities/Director
Client #4's HAIPC was dated 10/18/14 and client #5’s
HAIPC was dated 09/01/14. The HAIPC sections were
mostly blank and both assessments were not signed by
the nurse or the client, family member or responsible party.
Interview on 12/05/14 at 9:40 a.m. with the director
revealed he did not know why the HAIPCs were
incomplete.
These failures could place all 30 clients at risk for not being
accurately assessed and not receiving all needed services.
Slide 16
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The facility director is responsible for communicating with
the client, family member or responsible party regarding the
client and any changes in the client’s condition.
true
false
Slide 17
Activity: True/False
The correct answer is True.
The facility director is responsible for communicating with
the client, family member or responsible party regarding the
client and any changes in the client’s condition.
Slide 18
#10: A183
§98.62(a)(1)(A)(B) Staff Qualifications/Director
(A) The director must:
(i) have graduated from an accredited four-year college
or university, or have an associate’s degree with 3 years of
experience working in human services; or
(ii) be a registered nurse; or
(iii) meet the training and experience requirements for a
license as a nursing facility administrator; or
(iv) have met on 07/16/1989, the qualifications for the position
(B) The director must show evidence of 12 contact
hours of annual continuing education in at least two
areas.
This tag was a tie for number 6 in FY13
Slide 19
#10: A183
§98.62(a)(1)(A)(B) Staff Qualifications/Director
The facility failed to ensure that its director meet the
mandatory qualifications for a director.
Examples of conditions that may be cited include any one
of the following regarding the director:
• does not have a college degree or an associates degree;
• is not a registered nurse;
• does not meet the training and experience for a nursing
facility administrator; or
• does not have 12 hours of annual continuing education.
Slide 20
#10: A183 Example of a Citation
§98.62(a)(1)(A)(B) Staff Qualifications/Director
Based on record review and interview, the facility failed to provide
documentation to demonstrate that the Director/Licensed Vocational
Nurse (LVN) met the educational requirements for the Director position.
The findings were:
Inspector reviewed the Director/LVN's personnel file on 04/19/14 at
11:30 a.m. The director was hired on 09/02/13. There was no
documentation in the record that she met the qualifications to be a
director.
Interview with the director on 04/19/14 at 2:10 p.m., revealed that the
director had attended LVN school but did not meet any of the education
requirements for the position.
This failure could put all 35 clients at risk for not receiving necessary
care and services while attending the facility.
Slide 21
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The director of an DAHS can have four or more years
experience working in a health care setting to be qualified
for the position.
true
false
Slide 22
Activity: True/False
The correct answer is False.
The director of DAHS facility must have a college degree
or an associate degree with three years of experience
working in a health care setting.
Slide 23
#9: A118
§98.42(c)(1)(G)(iv) Personal Safety/Fire-Smoking
Regulations
(iv) Metal containers of substantial gauge or any UL or
FM-approved containers with self-closing cover
devices into which ashtrays can be emptied must
be provided in all areas where smoking is permitted.
This tag was not ranked in FY13.
Slide 24
#9: A118
§98.42(c)(1)(G)(iv) Personal Safety/Fire-Smoking
Regulations
The facility failed to provide the proper containers to allow
for the emptying of ashtrays in smoking areas.
Examples of conditions that might be cited include the
following:
• not having a metal U.L or F.M. approved container that is
a self-closing device;
• using a metal container that was not U.L. or F. M.
approved for disposing of cigarettes; or
• using a plastic trash container.
Slide 25
#9: A118 Example of a Citation
§98.42(c)(1)(G)(iv)Personal Safety/Fire-Smoking Regulations
Based on observation and interview, the facility failed to provide
a metal or U.L. or F.M. approved container with a self-closing
cover.
The findings were:
During initial rounds at 1:00 p.m. on 04/14/14, the inspector
observed that the facility did not have a container with a selfclosing cover device in the designated smoking area.
Interview on 04/14/14 at 1:20 p.m., the Administrator said he did
not know about the requirements for a container with a selfclosing cover device for the designated smoking area.
The failure to provide self-closing containers with covers, could
have placed all 24 clients (of this facility) at risk of fire related
injuries.
Slide 26
Activity: Multiple Choice
Directions: Read the statement and click the best option.
The facility must provide which type of container for clients
disposing of cigarettes or other smoking materials?
A. a metal U.L. or F.M. approved container that is a selfclosing device
B. a metal container
C. a plastic trash container
D. a glass ashtray
Slide 27
Activity: Multiple Choice
A is the correct answer.
A facility must provide a metal U.L. or F.M. approved
container that is a self-closing device for disposing of
smoking materials.
Slide 28
#8: A156
§98.61(b)(3)(A) General: Employment Prohibition
b) A facility must:
(3) before offering employment, search the employee
misconduct registry (EMR) established under
§253.007, Health and Safety Code, and the DADS
nurse aide registry (NAR) to determine if an
individual is designated in either registry as
unemployable.
(A) A facility must not employ a person who is listed
as unemployable in either registry.
This tag was not ranked in FY13.
Slide 29
#8: A156
§98.61(b)(3)(A) General: Employment Prohibition
The facility employed a person listed on the employee
misconduct registry or the nurse aide registry that was
unemployable.
Examples of conditions that might be cited include the
following:
• failure to have a system in place to search the Employee
Misconduct Registry (EMR) and the Nurse Aide Registry
(NAR); or
• if a facility offered employment to an applicant before
completing search of the EMR and NAR.
Slide 30
#8: A156 Example of a Citation
§98.61(b)(3)(A) General: Employment Prohibition
Based on record review and interview, the facility failed to search the
Employee Misconduct Registry (EMR) and the Nurse Aide Registry
(NAR) before offering employment to two recently hired employees
(Driver D and Attendant B).
The findings were:
Inspector on 06/04/14 at 3:30 p.m. reviewed personnel files for Driver B
and Attendant A. There was no documentation in either record that the
EMR/NAR had been searched before they were employed by the
facility.
Interview with the Director on 06/04/14 at 11:00 a.m., the Administrator
said she thought she had completed the EMR/NAR searches. She
could not provide documentation that the searches were completed.
This failure places all 27 clients at risk for abuse, neglect or
exploitation.
Slide 31
Activity: Multiple Choice
Directions: Read the statement and click the best option.
A facility can provide documentation by:
A. Stating that a criminal history check on employees has
been completed.
B. Creating a file and providing written documentation.
C. Completing the criminal history check in 3-4 weeks after
the employee starts to work at the facility.
D. Asking the employee to provide a written statement
that a criminal history check was completed on him/her
within the last six months.
Slide 32
Activity: Multiple Choice
B is the correct answer.
The facility should develop a system that provides written
documentation when they have searched the EMR or NAR.
This would be a method for a facility to provide written
documentation that the facility has fulfilled this requirement.
Slide 33
#7: A155
§98.61(b)(2) General: HSC Chapter 250 Compliance
b) A facility must:
(2) comply with the provisions of Chapter 250 of the
Health and Safety Code (relating to criminal history
checks of employees and applicants for employment in
certain facilities serving the elderly or persons with
disabilities).
This tag was tied for 8th place in FY13.
Slide 34
#7: A155
§98.61(b)(2) General: HSC Chapter 250 Compliance
If the facility did not complete criminal history checks on
employees and applicants.
Examples of conditions might include the following:
• no documentation regarding completing criminal history
checks on employees; or
• facility failure to have a system in place to ensure criminal
history checks are routinely completed for all employees.
Slide 35
#7: A155 Example of a Citation
§98.61(b)(2) General: HSC Chapter 250 Compliance
Based on record review and interview, the facility failed to conduct
criminal history checks on four employees (the director, the assistant
director and on two direct care employees). Record review on
12/10/14 at 9:45 a.m. of the personnel files revealed there was no
documentation that criminal history checks had been completed.
The findings were:
Interview on 12/10/14 at 10:45 a.m. the Administrator confirmed this
finding. The Administrator stated he had forgotten to complete criminal
history checks for these four employees.
This failure placed all 22 clients at risk for potential abuse, neglect and
exploitation.
Slide 36
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A DAHS can search either the EMR or the NAR to
determine if a potential employee can be employed by the
facility.
true
false
Slide 37
Activity: True/False
False is the correct answer.
A DAHS must search both the EMR and the NAR to
determine if a potential employee can be employed by the
facility.
Slide 38
#6: A146
§98.43(a)(7) Sanitation/General−Odors/Refuse/Hazards
(a) General
(7) The facility must be kept free of offensive odors,
accumulations of dirt, rubbish, dust, and hazards. Floors
must be maintained in good condition and cleaned
regularly; walls and ceilings must be structurally
maintained, repaired, and repainted or cleaned as needed.
Storage areas, attics, and cellars must be free of refuse
and extraneous materials.
This tag was ranked 10th in FY13.
Slide 39
#6: A146
§98.43(a)(7) Sanitation/General−Odors/Refuse/ Hazards
The facility failed to keep the building clean and well maintained.
Examples of conditions might include the following:
• Floor tiles in two restrooms are missing.
• Shower tiles are cracked, stained and chipped.
• Resting area is cluttered with empty cardboard boxes.
• Uncovered outdoor trash containers have overflowing trash.
• Restroom has a 2 X 3 foot area with no floor tiles.
• Kitchen walls and floor have several cracked and stained tiles.
Slide 40
#6: A146 Example of a Citation
§98.43(a)(7) Sanitation/General−Odors/Refuse/ Hazards
Based on observations and interview, the facility failed to keep the
building and grounds free of accumulation of dirt, rubbish, dust and
hazards in areas that were accessible to clients.
The findings were:
Environmental rounds conducted on 04/02/14 at 9:50 am., inspector
observed areas that were in disrepair. Floor tiles missing in two
restrooms, one had a 1 X 2 foot area and the other had a 1 X 1 foot
area.
Interview on 04/02/14 at 10:15 a.m., with the LVN confirmed the
findings and said the restrooms had been without tiles for six months.
These failures could affect all 39 clients by exposing them to an
environment with hazards and risk for injuries.
Slide 41
Activity: True/False
Directions: Read the statement and click either the True or
False button.
According to this regulation a facility must employ
housekeeping and maintenance staff to complete cleaning
and make maintenance repairs.
true
false
Slide 42
Activity: True/False
False is the correct answer.
The regulation does not specify that a facility must employ
housekeeping or maintenance staff. However, the facility
must be kept free of offensive odors, accumulations of dirt,
rubbish, dust and hazards.
Slide 43
#5: A247
§98.64(c)(1)-(5) Emergency Preparedness and Response/Plan
(c) Emergency Preparedness and Response Plan. A facility's plan must:
(1) include a risk assessment of all potential internal and external
emergency situations relevant to the facility operations and
geographical area;
(2) include a description of the facility's client population;
(3) include a description of the services and assistance needed by the
clients in an emergency situation;
(4) include a section for each core function of emergency management,
as described in subsection (d) of this section, that is based on a facility's
decision to either shelter-in-place or evacuate during an emergency; and
(5) include a fire safety plan that complies with subsection (f) of this section.
This tag was ranked 4th in FY13.
Slide 44
#5: A247
§98.64(c)(1)-(5) Emergency Preparedness and
Response/Plan
Examples of conditions the facility might not have in place in
their plan:
• a risk assessment of all potential internal and external
emergencies;
• a description of the facility's client population;
• a description of the services and assistance needed by the
clients in an emergency situation; or
• a safety plan that addresses events such as: a fire, failure of
heating and cooling systems, an explosion, a tornado, a flood,
a wildfire, terrorism, or a hazardous materials accident.
Slide 45
#5: A247 Example of a Citation
98.64(c)(1)-(5) Emergency Preparedness & Response/Plan
Based on interview and record review, the facility failed to
have a copy of the facility's Emergency Preparedness Plan
(EPP) available for staff at the facility.
The findings included:
Record review on 03/20/14 revealed the facility did not
have a EPP for disasters to identify:
A) the facility's Emergency Preparedness Coordinator
(EPC) with authority to manage the facility's response
to an emergency situation.
B) the name and/or contact information of the designated
city/county local Emergency Management Coordinator
for the area.
Slide 46
#5: A247 (continued)
98.64(c)(1)-(5) Emergency Preparedness & Response/Plan
C) Include an assessment of clients for emergency services and
identified facility's special needs clients.
D) Include evacuation transportation for alternate transportation
arrangements.
E) Include maps that showed the destination and routes to
designated and established shelters and had no written
mutual agreement with a receiving facility.
F) Include a section for transfer of records, emergency
equipment, and supplies procedures.
Interview on 03/20/14 at 2:20 p.m. with the facility Director
revealed she did not have a copy of the EPP available at the
facility. She stated she had to call her Regional office to request
a copy.
Slide 47
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Which of the following items would not appear in an
Emergency Preparedness and Response Plan?
A. Risk assessments for all potential internal/external
emergencies and a fire safety plan
B. A description of facility clients, description of services
and clients personalized assistive needs
C. A section for each core function of emergency
management (such as a fire, a power outage, or a
tornado)
D. Texas Homeland Security Strategic Plan
Slide 48
Activity: Multiple Choice
D is the correct answer.
Chapter 98 rules do not require a provider to make the
Texas Homeland Security Strategic Plan part of its
Emergency Preparedness and Response Plan.
Slide 49
#4: A207
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
(2) Facility nurse. The facility nurse is responsible for:
(A) assessing the client's nursing and medical needs;
(B) developing a client's individual plan of care;
(C) obtaining physician's orders for medication and treatments
to be administered;
(D) determining whether self-administered medications have
been appropriately taken, applied, or used;
(E) entering, dating, and signing monthly progress notes on
medical care provided;
(F) administering medication and treatments;
(G) providing health education; and
(H) maintaining medical records.
This tag was ranked 3rd in FY13.
Slide 50
#4: A207 Example of a Citation
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
Based on record review and interview, the facility's Licensed
Vocational Nurse (LVN) failed to obtain valid physician's
orders to perform fasting blood sugar (FBS) checks for three
(C#3, C#5, and C#6) of six clients whose clinical records were
reviewed.
The findings were:
• C#3's Nursing Monthly Assessment (NMA) dated 02/28/14
found C#3 had a FBS check done on 05/21/14 at 7:00 a.m.
(result was 66). Physician's orders for C#3 were not signed
by the physician and not dated.
• C#5's NMA dated 02/09/14 documented C#5 had a FBS
check done on 02/01/14 at 9:30 a.m. (result was 125).
Physician's orders for C#5 were not signed by the physician
and not dated.
Slide 51
#4: A207
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
The facility failed to ensure the facility nurse fulfilled the
responsibilities of the position.
Examples of conditions that might be cited include the
following:
• failing to obtain valid physician's orders prior to giving
prescribed medications to clients; or
• developing and maintaining individual plans of care for
clients.
Slide 52
#4: A207 (continued)
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
• C#6's Skilled Nursing Monthly Assessment dated
06/09/14 documented C#6 had a FBS check done on
06/09/14 at 8:30 a.m. the result was 182. Physician's
orders were not signed by the physician or dated.
Interview on 10/15/14 at 9:50 a.m., the Director/ LVN said
she had been calling the clients' physician to get signed
copies of the orders. The LVN said that the physician’s
nurse said she was still waiting for the physician to sign the
orders.
These failures could result in all 18 clients' medications
being omitted or administered inaccurately.
Slide 53
Activity: Multiple Choice
Directions: Choose the correct answer to the Multiple Choice
question.
Which of the following responsibilities must the facility ensure the
facility nurse fulfills?
A. Assess the client's nursing and medical needs and
develop an individual plan of care.
B. Obtain physician's orders for medication and
treatments to be administered.
C. Enter date and sign monthly progress notes on medical care
provided.
D. All are correct.
Slide 54
Activity: Multiple Choice
D is the correct answer.
A nurse is responsible for all of the tasks listed.
Slide 55
#3: A117
§98.42(c)(1)(G)(iii)
Personal Safety/Fire-Smoking Regulations
(iii) Ashtrays of noncombustible material and safe design
must be provided in all areas where smoking is
permitted.
This tag was ranked 5th in FY13.
Slide 56
#3: A117
§98.42(c)(1)(G)(iii) Personal Safety/Fire-Smoking
Regulations
The facility failed to provide the proper ashtrays in areas
where smoking is permitted.
Examples of conditions that might be cited include the
following:
• not providing ashtrays of safe design in areas where
smoking is permitted; or
• use of metal containers such as tin buckets or other
material that is noncombustible for ashtrays.
Slide 57
#3: A117 Example of a Citation
§98.42(c)(1)(G)(iii) Personal Safety/Fire-Smoking Regulations
Based on observation and interview, the facility failed to provide ashtrays
of safe design in areas where smoking was permitted.
The findings were:
During environmental rounds on 04/14/14 at 1:00 p.m., accompanied by
the facility Administrator, inspector observed the designated smoking area
had a metal ashtray. The ashtray used did not have an indentation/notch
around the perimeter of the ashtray. This would allow the smoker to place
the cigarette down on the ashtray in a sanitary manner and prevent it from
rolling off the ashtray or into the disposed cigarette butts in the ashtray.
In an interview on 04/14/14 at 3:00 p.m., the Administrator said he was not
aware of the requirements for ashtrays of safe design.
This failure could place all 24 clients at risk for injury if a fire developed.
Slide 58
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Which kind of ashtray are facilities required to provide in
designated smoking areas?
A. Empty tuna cans or food service bowls
B. Ceramic soap dishes
C. Ashtrays of noncombustible material and safe design
D. Aluminum soda pop cans
Slide 59
Activity: Multiple Choice
C is the correct answer.
A facility must provide ashtrays of noncombustible material
and safe design in its designated smoking area.
Slide 60
#2: A205
§98.62(c) Communicable Diseases/Staff Health
(c) Staff health. All direct staff must be free of communicable diseases.
(1) The facility must screen all employees for tuberculosis (TB) within
two weeks of employment and annually, according to Center for
Disease Control (CDC) screening guidelines. All persons providing
services under an outside resource contract must also screen all
employees for tuberculosis within two weeks of employment and
annually according to CDC screening guidelines. When requested
to do so by the facility, persons providing services under an
outside resource contract must provide evidence of compliance
with this requirement.
This tag was also ranked 2nd in FY13.
Slide 61
#2: A205
§98.62(c) Communicable Diseases/Staff Health
If the facility did not ensure that its employees were free of
communicable diseases, through tuberculosis screening or
by excluding them from work while communicable.
Examples of situations that might be cited include the
following:
• failure to have a system in place to ensure its
employees were free of communicable diseases; or
• direct service staff were not screened for TB within two
weeks of employment and annually.
Slide 62
#2: A205 Example of a Citation
§98.62(c) Communicable Diseases/Staff Health
Based on record reviews and interview, the facility failed to
screen employees for TB within two weeks of employment and
annually. The facility could not provide documentation for two
employees of six employees whose personnel records were
reviewed on 12/12/14 at 1:30 p.m.
The findings were:
• Activity Director was hired on 01/13/14
• Driver A was hired in 03/03/13
Also, there was no documentation for annual TB screening for
these two employees. The director was interviewed on 2/12/14
at 10:15 a.m., she stated she was working on getting the
information on screening employees current.
These failures could place all 41 clients at risk to exposure to
TB.
Slide 63
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A facility must screen all employees for tuberculosis (TB)
within two weeks of employment and annually, according to
Center for Disease Control (CDC) screening guidelines.
true
false
Slide 64
Activity: True/False
True is the correct answer.
A facility must screen all employees for TB within two
weeks of employment and annually, according to CDC
screening guidelines.
Slide 65
#1: A150
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
(b) Kitchen.
(1) The Department of State Health Services (DSHS)
rules in 25 TAC §§229.161 - 229.171 and §§229.173 –
229.175 (relating to Texas Food Establishments) and
local health ordinances or requirements must be
observed in the storage, preparation, and distribution
of food; in the cleaning of dishes, equipment, and work
area; and in the storage and disposal of waste.
This tag was also ranked 1st in FY13.
Slide 66
#1: A150
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
The facility did not comply with state requirements and
local health ordinances relating to Texas food
establishments.
Examples of conditions that might be cited include the
following:
• Freezer with opened, undated frozen packages of
pancakes and biscuits.
• Refrigerator contained undated, unsealed food items and
did not have "opened on" dates.
• Food storage pantry with food cases stored directly on the
floor.
Slide 67
#1: A150 Example of a Citation
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
Based on observations and interview the facility failed to follow
the Texas Food Establishment Rules on kitchen sanitation.
The findings were:
Inspector observed on 04/04/15 at 9:30 a.m. the following:
• two bags of opened corn chips not dated or labeled; and
• two bags of raw meat left to thaw on the kitchen counter (the
meat was not submerged in water).
Interview on 04/04/15 at 9:45 a.m. with Cook A revealed she was
aware of the dating and labeling rule.
These failures could place all 36 clients at risk for food borne
illnesses.
Slide 68
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The sanitation in the kitchen refers to the source of the food
obtained by the facility and all of the safety factors involved in
the handling of the food.
true
false
Slide 69
Activity: True/False
True is the correct answer.
The sanitation in the kitchen refers to the source of the food
obtained by the facility and all of the safety factors involved
in handling of the food.
Slide 70
Correcting Deficient Practices
The facility needs to:
• Analyze the problem by asking what happened and
identify the root cause;
• Address the problem by developing and implementing a
Plan of Correction; and
• Improve policies and procedures within systems to ensure
lasting consistent compliance.
Slide 71
Conclusion
These Top 10 violations tend to remain on Top 10 lists
because they involve key facility systems, such as food
service, maintenance, abuse prevention, staff
responsibilities, personal safety and emergency
preparedness. These are areas that involve the interaction
of many different staff in multiple departments.
The expectation is the facility will analyze the problem with
the goal of developing a solution that is sustainable. This
requires the facility to understand the cause of the problem
and whether the problem is linked to a failure in the
facility’s system(s).
Slide 72
Conclusion (continued)
The facility can devise an appropriate and lasting solution
to correct any existing or potential problems.
Substantial compliance can be achieved and maintained by
understanding deficient practices and implementing the
rules.
The facility must consistently monitor its practices and
make adjustments as necessary.
Slide 73
DADS Websites
This is DADS home page—
www.dads.state.tx.us
DADS provides joint trainings. The Joint Training website
contains the current schedule and a description of each
course. These courses provide continuing education for
some disciplines.
Joint Training Seminars—
www.dads.state.tx.us/providers/training/jointtraining.cfm
Slide 74
Contact
If you have questions or need additional information,
contact:
DADS Regulatory Services
Policy, Rules and Curriculum Development
512-438-3161
Ask for an DAHS program specialist.
10 MOST FREQUENTLY
CITED VIOLATIONS
Day Activity and Health Services Facilities*
July 2015
*Adult Day Care Facilities name will be changed to Day Activity and Health
Services Facilities effective 09-01-15
Slide 2
Welcome
This computer based training (CBT) was designed to
inform you about the 10 most frequently cited violations in
Day Activity and Health Services Facilities for the Fiscal
Year 2014.
Navigation
Click anywhere in the screen to go forward one slide at a
time.
Scroll up to go back.
Click the exit button in the top right hand corner to leave
the program.
Slide 3
Inspection Process
Inspectors base their decisions on the regulations from the following
documents:
•
•
•
•
Texas Administrative Code, Title 40, Part 1, Chapter 98: Adult Day
Care and Day Activity and Health Services Requirements;
Texas Human Resource Code, Title 6, Services for the
Elderly Chapter 103: Adult Day Care;
Texas Health and Safety, Title 4, Chapter 253: Employee
Misconduct Registry;
Texas Health and Safety Code, Title 4, Chapter 250: Nurse Aide
Registry and Criminal History Checks of Employees and
Applicants for Employment in Certain Facilities of Employees
and Applicants for Employment in Certain Facilities Serving Elderly
Persons with Disabilities.
Slide 4
State Rules
The Texas Administrative Code (TAC) chapter 98 contains
the state licensure rules governing DAHS that are enacted
under the authority of the Health Safety Code (HSC)
chapter 247.
Inspectors use the rules in Chapter 98 to determine
whether the facility is in compliance. Citations are based
on noncompliance with the standards.
Slide 5
Inspection Focus
DADS inspects DAHS to determine compliance with
minimum standards.
The inspection team may be just one person.
The inspection process is intended to:
• protect the health and safety and rights of clients; and
• determine compliance with regulations.
Slide 6
Inspection Focus
Violations can include both actual and potential negative
outcomes.
Inspectors determine whether the facilities are in
compliance during the inspection.
Slide 7
Inspection Focus
During the inspection, inspectors assess the facility’s:
• Compliance with clients’ rights requirements;
• Compliance with clients’ quality of life requirements;
• Compliance with clients’ quality of care requirements;
• Accuracy of clients’ comprehensive assessments;
• Adequacy of individualized care plans based on
comprehensive assessments; and
• Effectiveness of the physical environment to empower
clients, accommodate their needs and maintain safety.
Slide 8
DADS Annual Report
DADS is required to compile and report inspection and
enforcement data every year. This data is captured in the
Regulatory Services Annual Report.
Part of this report includes the top 10 violations cited during
the fiscal year covered in the report.
DADS Annual Report is available online at:
http://www.dads.state.tx.us/providers/reports/sb190/index.h
tml
Slide 9
DADS Annual Report
This presentation is based on the data contained in the
Regulatory Services FY14 Annual Report which covers the
period of 9/1/13 to 8/31/14.
Other than minor changes in position within the top 10, eight of
the top 10 violations listed in the FY13 annual report continue to
be top 10 issues in FY14.
The top 10 violations in the FY14 annual report are listed in
order from least frequently cited (#10) to most frequently cited
(#1).
Note: The violations in this presentation are just a summary of
violations (they are not complete violations).
Slide 10
Learning Objectives
In this course, you will:
• identify the 10 most frequently cited violations; and
• evaluate examples of the most frequently cited violations.
Slide 11
Violations Chart for FY14 and FY13
Rank
Tag Number
Tag Title
FY14
FY13
§98.62(d)(1)(A-H)
Staff Responsibilities/Director:
10
tied for 7th
§98.62(a)(1)(A)(B)
Staff Qualifications/Director
10
tied for 6th
§98.42(c)(1)(G)(iv)
Personal Safety/Fire-Smoking Regulations
9
not ranked
§98.61(b)(3)(A)
General: Employment Prohibition
8
not ranked
§98.61(b)(2)
General: HSC Chapter 250 Compliance
7
tied for 8th
§98.43(a)(7)
Sanitation/General−Odors/Refuse/Hazards
6
10
§98.64(c)(1)-(5)
Emergency Preparedness and Response/Plan
5
4
§98.62(d)(2)(A-H)
Staff Responsibilities/Nurse
4
3
§98.42(c)(1)(G)(iii)
Personal Safety/Fire-Smoking Regulations
3
5
§98.62(c)
Communicable Diseases/Staff Health
2
2
§98.43(b)(1)
Sanitation/Kitchen−Food Service Sanitation
1
1
Slide 12
#10: A206
§98.62(d)(1)(A-H) Staff Responsibilities/Director
(1) Facility director. The facility director is responsible for:
(A) managing the adult day care program and/or the facility;
(B) training and supervising facility staff;
(C) monitoring the facility building and grounds to ensure compliance;
(D) maintaining all financial and client records;
(E) developing relationships with community groups and agencies for
identification and referral of clients;
(F) maintaining communication with the client's family members or
responsible parties;
(G) assuring the development and maintenance of the individual plan of
care; and
(H) ensuring that, if he/she serves as the nurse consultant during the same
eight- hours-per-day period, he/she is fulfilling his/her responsibility as
director.
This tag was tied for number 7 in FY13.
Slide 13
#10: A206
§98.62(d)(1)(A-H) Staff Responsibilities/Director
The facility must ensure the director fulfills the responsibilities of the
position.
Examples of conditions cited might include not having systems in place
for:
• training and supervising facility staff;
• developing relationships with community groups and
agencies for referral of clients;
• communicating with the client's family members or
responsible parties; and
• developing and maintaining individual plans of care.
Slide 14
#10: A206 Example of a Citation
§98.62(d)(1)(A-H) Staff Responsibilities/Director
Based on record reviews and interview, the facility’s
director failed to ensure the development and maintenance
of the Health Assessment/Individual Plan of Care (HAIPC)
for three clients (#s 1,4 and 5) of five clients whose records
were reviewed.
The findings were:
• #1’s care plan had not been completed
• #4's plan of care was incomplete
• #5’s plan of care was incomplete
Clients #s 1, 4 and 5 enrolled in the facility during the last
six months.
Slide 15
#10: A206 (continued)
§98.62(d)(1)(A-H) Staff Responsibilities/Director
Client #4's HAIPC was dated 10/18/14 and client #5’s
HAIPC was dated 09/01/14. The HAIPC sections were
mostly blank and both assessments were not signed by
the nurse or the client, family member or responsible party.
Interview on 12/05/14 at 9:40 a.m. with the director
revealed he did not know why the HAIPCs were
incomplete.
These failures could place all 30 clients at risk for not being
accurately assessed and not receiving all needed services.
Slide 16
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The facility director is responsible for communicating with
the client, family member or responsible party regarding the
client and any changes in the client’s condition.
true
false
Slide 17
Activity: True/False
The correct answer is True.
The facility director is responsible for communicating with
the client, family member or responsible party regarding the
client and any changes in the client’s condition.
Slide 18
#10: A183
§98.62(a)(1)(A)(B) Staff Qualifications/Director
(A) The director must:
(i) have graduated from an accredited four-year college
or university, or have an associate’s degree with 3 years of
experience working in human services; or
(ii) be a registered nurse; or
(iii) meet the training and experience requirements for a
license as a nursing facility administrator; or
(iv) have met on 07/16/1989, the qualifications for the position
(B) The director must show evidence of 12 contact
hours of annual continuing education in at least two
areas.
This tag was a tie for number 6 in FY13
Slide 19
#10: A183
§98.62(a)(1)(A)(B) Staff Qualifications/Director
The facility failed to ensure that its director meet the
mandatory qualifications for a director.
Examples of conditions that may be cited include any one
of the following regarding the director:
• does not have a college degree or an associates degree;
• is not a registered nurse;
• does not meet the training and experience for a nursing
facility administrator; or
• does not have 12 hours of annual continuing education.
Slide 20
#10: A183 Example of a Citation
§98.62(a)(1)(A)(B) Staff Qualifications/Director
Based on record review and interview, the facility failed to provide
documentation to demonstrate that the Director/Licensed Vocational
Nurse (LVN) met the educational requirements for the Director position.
The findings were:
Inspector reviewed the Director/LVN's personnel file on 04/19/14 at
11:30 a.m. The director was hired on 09/02/13. There was no
documentation in the record that she met the qualifications to be a
director.
Interview with the director on 04/19/14 at 2:10 p.m., revealed that the
director had attended LVN school but did not meet any of the education
requirements for the position.
This failure could put all 35 clients at risk for not receiving necessary
care and services while attending the facility.
Slide 21
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The director of an DAHS can have four or more years
experience working in a health care setting to be qualified
for the position.
true
false
Slide 22
Activity: True/False
The correct answer is False.
The director of DAHS facility must have a college degree
or an associate degree with three years of experience
working in a health care setting.
Slide 23
#9: A118
§98.42(c)(1)(G)(iv) Personal Safety/Fire-Smoking
Regulations
(iv) Metal containers of substantial gauge or any UL or
FM-approved containers with self-closing cover
devices into which ashtrays can be emptied must
be provided in all areas where smoking is permitted.
This tag was not ranked in FY13.
Slide 24
#9: A118
§98.42(c)(1)(G)(iv) Personal Safety/Fire-Smoking
Regulations
The facility failed to provide the proper containers to allow
for the emptying of ashtrays in smoking areas.
Examples of conditions that might be cited include the
following:
• not having a metal U.L or F.M. approved container that is
a self-closing device;
• using a metal container that was not U.L. or F. M.
approved for disposing of cigarettes; or
• using a plastic trash container.
Slide 25
#9: A118 Example of a Citation
§98.42(c)(1)(G)(iv)Personal Safety/Fire-Smoking Regulations
Based on observation and interview, the facility failed to provide
a metal or U.L. or F.M. approved container with a self-closing
cover.
The findings were:
During initial rounds at 1:00 p.m. on 04/14/14, the inspector
observed that the facility did not have a container with a selfclosing cover device in the designated smoking area.
Interview on 04/14/14 at 1:20 p.m., the Administrator said he did
not know about the requirements for a container with a selfclosing cover device for the designated smoking area.
The failure to provide self-closing containers with covers, could
have placed all 24 clients (of this facility) at risk of fire related
injuries.
Slide 26
Activity: Multiple Choice
Directions: Read the statement and click the best option.
The facility must provide which type of container for clients
disposing of cigarettes or other smoking materials?
A. a metal U.L. or F.M. approved container that is a selfclosing device
B. a metal container
C. a plastic trash container
D. a glass ashtray
Slide 27
Activity: Multiple Choice
A is the correct answer.
A facility must provide a metal U.L. or F.M. approved
container that is a self-closing device for disposing of
smoking materials.
Slide 28
#8: A156
§98.61(b)(3)(A) General: Employment Prohibition
b) A facility must:
(3) before offering employment, search the employee
misconduct registry (EMR) established under
§253.007, Health and Safety Code, and the DADS
nurse aide registry (NAR) to determine if an
individual is designated in either registry as
unemployable.
(A) A facility must not employ a person who is listed
as unemployable in either registry.
This tag was not ranked in FY13.
Slide 29
#8: A156
§98.61(b)(3)(A) General: Employment Prohibition
The facility employed a person listed on the employee
misconduct registry or the nurse aide registry that was
unemployable.
Examples of conditions that might be cited include the
following:
• failure to have a system in place to search the Employee
Misconduct Registry (EMR) and the Nurse Aide Registry
(NAR); or
• if a facility offered employment to an applicant before
completing search of the EMR and NAR.
Slide 30
#8: A156 Example of a Citation
§98.61(b)(3)(A) General: Employment Prohibition
Based on record review and interview, the facility failed to search the
Employee Misconduct Registry (EMR) and the Nurse Aide Registry
(NAR) before offering employment to two recently hired employees
(Driver D and Attendant B).
The findings were:
Inspector on 06/04/14 at 3:30 p.m. reviewed personnel files for Driver B
and Attendant A. There was no documentation in either record that the
EMR/NAR had been searched before they were employed by the
facility.
Interview with the Director on 06/04/14 at 11:00 a.m., the Administrator
said she thought she had completed the EMR/NAR searches. She
could not provide documentation that the searches were completed.
This failure places all 27 clients at risk for abuse, neglect or
exploitation.
Slide 31
Activity: Multiple Choice
Directions: Read the statement and click the best option.
A facility can provide documentation by:
A. Stating that a criminal history check on employees has
been completed.
B. Creating a file and providing written documentation.
C. Completing the criminal history check in 3-4 weeks after
the employee starts to work at the facility.
D. Asking the employee to provide a written statement
that a criminal history check was completed on him/her
within the last six months.
Slide 32
Activity: Multiple Choice
B is the correct answer.
The facility should develop a system that provides written
documentation when they have searched the EMR or NAR.
This would be a method for a facility to provide written
documentation that the facility has fulfilled this requirement.
Slide 33
#7: A155
§98.61(b)(2) General: HSC Chapter 250 Compliance
b) A facility must:
(2) comply with the provisions of Chapter 250 of the
Health and Safety Code (relating to criminal history
checks of employees and applicants for employment in
certain facilities serving the elderly or persons with
disabilities).
This tag was tied for 8th place in FY13.
Slide 34
#7: A155
§98.61(b)(2) General: HSC Chapter 250 Compliance
If the facility did not complete criminal history checks on
employees and applicants.
Examples of conditions might include the following:
• no documentation regarding completing criminal history
checks on employees; or
• facility failure to have a system in place to ensure criminal
history checks are routinely completed for all employees.
Slide 35
#7: A155 Example of a Citation
§98.61(b)(2) General: HSC Chapter 250 Compliance
Based on record review and interview, the facility failed to conduct
criminal history checks on four employees (the director, the assistant
director and on two direct care employees). Record review on
12/10/14 at 9:45 a.m. of the personnel files revealed there was no
documentation that criminal history checks had been completed.
The findings were:
Interview on 12/10/14 at 10:45 a.m. the Administrator confirmed this
finding. The Administrator stated he had forgotten to complete criminal
history checks for these four employees.
This failure placed all 22 clients at risk for potential abuse, neglect and
exploitation.
Slide 36
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A DAHS can search either the EMR or the NAR to
determine if a potential employee can be employed by the
facility.
true
false
Slide 37
Activity: True/False
False is the correct answer.
A DAHS must search both the EMR and the NAR to
determine if a potential employee can be employed by the
facility.
Slide 38
#6: A146
§98.43(a)(7) Sanitation/General−Odors/Refuse/Hazards
(a) General
(7) The facility must be kept free of offensive odors,
accumulations of dirt, rubbish, dust, and hazards. Floors
must be maintained in good condition and cleaned
regularly; walls and ceilings must be structurally
maintained, repaired, and repainted or cleaned as needed.
Storage areas, attics, and cellars must be free of refuse
and extraneous materials.
This tag was ranked 10th in FY13.
Slide 39
#6: A146
§98.43(a)(7) Sanitation/General−Odors/Refuse/ Hazards
The facility failed to keep the building clean and well maintained.
Examples of conditions might include the following:
• Floor tiles in two restrooms are missing.
• Shower tiles are cracked, stained and chipped.
• Resting area is cluttered with empty cardboard boxes.
• Uncovered outdoor trash containers have overflowing trash.
• Restroom has a 2 X 3 foot area with no floor tiles.
• Kitchen walls and floor have several cracked and stained tiles.
Slide 40
#6: A146 Example of a Citation
§98.43(a)(7) Sanitation/General−Odors/Refuse/ Hazards
Based on observations and interview, the facility failed to keep the
building and grounds free of accumulation of dirt, rubbish, dust and
hazards in areas that were accessible to clients.
The findings were:
Environmental rounds conducted on 04/02/14 at 9:50 am., inspector
observed areas that were in disrepair. Floor tiles missing in two
restrooms, one had a 1 X 2 foot area and the other had a 1 X 1 foot
area.
Interview on 04/02/14 at 10:15 a.m., with the LVN confirmed the
findings and said the restrooms had been without tiles for six months.
These failures could affect all 39 clients by exposing them to an
environment with hazards and risk for injuries.
Slide 41
Activity: True/False
Directions: Read the statement and click either the True or
False button.
According to this regulation a facility must employ
housekeeping and maintenance staff to complete cleaning
and make maintenance repairs.
true
false
Slide 42
Activity: True/False
False is the correct answer.
The regulation does not specify that a facility must employ
housekeeping or maintenance staff. However, the facility
must be kept free of offensive odors, accumulations of dirt,
rubbish, dust and hazards.
Slide 43
#5: A247
§98.64(c)(1)-(5) Emergency Preparedness and Response/Plan
(c) Emergency Preparedness and Response Plan. A facility's plan must:
(1) include a risk assessment of all potential internal and external
emergency situations relevant to the facility operations and
geographical area;
(2) include a description of the facility's client population;
(3) include a description of the services and assistance needed by the
clients in an emergency situation;
(4) include a section for each core function of emergency management,
as described in subsection (d) of this section, that is based on a facility's
decision to either shelter-in-place or evacuate during an emergency; and
(5) include a fire safety plan that complies with subsection (f) of this section.
This tag was ranked 4th in FY13.
Slide 44
#5: A247
§98.64(c)(1)-(5) Emergency Preparedness and
Response/Plan
Examples of conditions the facility might not have in place in
their plan:
• a risk assessment of all potential internal and external
emergencies;
• a description of the facility's client population;
• a description of the services and assistance needed by the
clients in an emergency situation; or
• a safety plan that addresses events such as: a fire, failure of
heating and cooling systems, an explosion, a tornado, a flood,
a wildfire, terrorism, or a hazardous materials accident.
Slide 45
#5: A247 Example of a Citation
98.64(c)(1)-(5) Emergency Preparedness & Response/Plan
Based on interview and record review, the facility failed to
have a copy of the facility's Emergency Preparedness Plan
(EPP) available for staff at the facility.
The findings included:
Record review on 03/20/14 revealed the facility did not
have a EPP for disasters to identify:
A) the facility's Emergency Preparedness Coordinator
(EPC) with authority to manage the facility's response
to an emergency situation.
B) the name and/or contact information of the designated
city/county local Emergency Management Coordinator
for the area.
Slide 46
#5: A247 (continued)
98.64(c)(1)-(5) Emergency Preparedness & Response/Plan
C) Include an assessment of clients for emergency services and
identified facility's special needs clients.
D) Include evacuation transportation for alternate transportation
arrangements.
E) Include maps that showed the destination and routes to
designated and established shelters and had no written
mutual agreement with a receiving facility.
F) Include a section for transfer of records, emergency
equipment, and supplies procedures.
Interview on 03/20/14 at 2:20 p.m. with the facility Director
revealed she did not have a copy of the EPP available at the
facility. She stated she had to call her Regional office to request
a copy.
Slide 47
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Which of the following items would not appear in an
Emergency Preparedness and Response Plan?
A. Risk assessments for all potential internal/external
emergencies and a fire safety plan
B. A description of facility clients, description of services
and clients personalized assistive needs
C. A section for each core function of emergency
management (such as a fire, a power outage, or a
tornado)
D. Texas Homeland Security Strategic Plan
Slide 48
Activity: Multiple Choice
D is the correct answer.
Chapter 98 rules do not require a provider to make the
Texas Homeland Security Strategic Plan part of its
Emergency Preparedness and Response Plan.
Slide 49
#4: A207
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
(2) Facility nurse. The facility nurse is responsible for:
(A) assessing the client's nursing and medical needs;
(B) developing a client's individual plan of care;
(C) obtaining physician's orders for medication and treatments
to be administered;
(D) determining whether self-administered medications have
been appropriately taken, applied, or used;
(E) entering, dating, and signing monthly progress notes on
medical care provided;
(F) administering medication and treatments;
(G) providing health education; and
(H) maintaining medical records.
This tag was ranked 3rd in FY13.
Slide 50
#4: A207 Example of a Citation
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
Based on record review and interview, the facility's Licensed
Vocational Nurse (LVN) failed to obtain valid physician's
orders to perform fasting blood sugar (FBS) checks for three
(C#3, C#5, and C#6) of six clients whose clinical records were
reviewed.
The findings were:
• C#3's Nursing Monthly Assessment (NMA) dated 02/28/14
found C#3 had a FBS check done on 05/21/14 at 7:00 a.m.
(result was 66). Physician's orders for C#3 were not signed
by the physician and not dated.
• C#5's NMA dated 02/09/14 documented C#5 had a FBS
check done on 02/01/14 at 9:30 a.m. (result was 125).
Physician's orders for C#5 were not signed by the physician
and not dated.
Slide 51
#4: A207
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
The facility failed to ensure the facility nurse fulfilled the
responsibilities of the position.
Examples of conditions that might be cited include the
following:
• failing to obtain valid physician's orders prior to giving
prescribed medications to clients; or
• developing and maintaining individual plans of care for
clients.
Slide 52
#4: A207 (continued)
§98.62(d)(2)(A-H) Staff Responsibilities/Nurse
• C#6's Skilled Nursing Monthly Assessment dated
06/09/14 documented C#6 had a FBS check done on
06/09/14 at 8:30 a.m. the result was 182. Physician's
orders were not signed by the physician or dated.
Interview on 10/15/14 at 9:50 a.m., the Director/ LVN said
she had been calling the clients' physician to get signed
copies of the orders. The LVN said that the physician’s
nurse said she was still waiting for the physician to sign the
orders.
These failures could result in all 18 clients' medications
being omitted or administered inaccurately.
Slide 53
Activity: Multiple Choice
Directions: Choose the correct answer to the Multiple Choice
question.
Which of the following responsibilities must the facility ensure the
facility nurse fulfills?
A. Assess the client's nursing and medical needs and
develop an individual plan of care.
B. Obtain physician's orders for medication and
treatments to be administered.
C. Enter date and sign monthly progress notes on medical care
provided.
D. All are correct.
Slide 54
Activity: Multiple Choice
D is the correct answer.
A nurse is responsible for all of the tasks listed.
Slide 55
#3: A117
§98.42(c)(1)(G)(iii)
Personal Safety/Fire-Smoking Regulations
(iii) Ashtrays of noncombustible material and safe design
must be provided in all areas where smoking is
permitted.
This tag was ranked 5th in FY13.
Slide 56
#3: A117
§98.42(c)(1)(G)(iii) Personal Safety/Fire-Smoking
Regulations
The facility failed to provide the proper ashtrays in areas
where smoking is permitted.
Examples of conditions that might be cited include the
following:
• not providing ashtrays of safe design in areas where
smoking is permitted; or
• use of metal containers such as tin buckets or other
material that is noncombustible for ashtrays.
Slide 57
#3: A117 Example of a Citation
§98.42(c)(1)(G)(iii) Personal Safety/Fire-Smoking Regulations
Based on observation and interview, the facility failed to provide ashtrays
of safe design in areas where smoking was permitted.
The findings were:
During environmental rounds on 04/14/14 at 1:00 p.m., accompanied by
the facility Administrator, inspector observed the designated smoking area
had a metal ashtray. The ashtray used did not have an indentation/notch
around the perimeter of the ashtray. This would allow the smoker to place
the cigarette down on the ashtray in a sanitary manner and prevent it from
rolling off the ashtray or into the disposed cigarette butts in the ashtray.
In an interview on 04/14/14 at 3:00 p.m., the Administrator said he was not
aware of the requirements for ashtrays of safe design.
This failure could place all 24 clients at risk for injury if a fire developed.
Slide 58
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Which kind of ashtray are facilities required to provide in
designated smoking areas?
A. Empty tuna cans or food service bowls
B. Ceramic soap dishes
C. Ashtrays of noncombustible material and safe design
D. Aluminum soda pop cans
Slide 59
Activity: Multiple Choice
C is the correct answer.
A facility must provide ashtrays of noncombustible material
and safe design in its designated smoking area.
Slide 60
#2: A205
§98.62(c) Communicable Diseases/Staff Health
(c) Staff health. All direct staff must be free of communicable diseases.
(1) The facility must screen all employees for tuberculosis (TB) within
two weeks of employment and annually, according to Center for
Disease Control (CDC) screening guidelines. All persons providing
services under an outside resource contract must also screen all
employees for tuberculosis within two weeks of employment and
annually according to CDC screening guidelines. When requested
to do so by the facility, persons providing services under an
outside resource contract must provide evidence of compliance
with this requirement.
This tag was also ranked 2nd in FY13.
Slide 61
#2: A205
§98.62(c) Communicable Diseases/Staff Health
If the facility did not ensure that its employees were free of
communicable diseases, through tuberculosis screening or
by excluding them from work while communicable.
Examples of situations that might be cited include the
following:
• failure to have a system in place to ensure its
employees were free of communicable diseases; or
• direct service staff were not screened for TB within two
weeks of employment and annually.
Slide 62
#2: A205 Example of a Citation
§98.62(c) Communicable Diseases/Staff Health
Based on record reviews and interview, the facility failed to
screen employees for TB within two weeks of employment and
annually. The facility could not provide documentation for two
employees of six employees whose personnel records were
reviewed on 12/12/14 at 1:30 p.m.
The findings were:
• Activity Director was hired on 01/13/14
• Driver A was hired in 03/03/13
Also, there was no documentation for annual TB screening for
these two employees. The director was interviewed on 2/12/14
at 10:15 a.m., she stated she was working on getting the
information on screening employees current.
These failures could place all 41 clients at risk to exposure to
TB.
Slide 63
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A facility must screen all employees for tuberculosis (TB)
within two weeks of employment and annually, according to
Center for Disease Control (CDC) screening guidelines.
true
false
Slide 64
Activity: True/False
True is the correct answer.
A facility must screen all employees for TB within two
weeks of employment and annually, according to CDC
screening guidelines.
Slide 65
#1: A150
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
(b) Kitchen.
(1) The Department of State Health Services (DSHS)
rules in 25 TAC §§229.161 - 229.171 and §§229.173 –
229.175 (relating to Texas Food Establishments) and
local health ordinances or requirements must be
observed in the storage, preparation, and distribution
of food; in the cleaning of dishes, equipment, and work
area; and in the storage and disposal of waste.
This tag was also ranked 1st in FY13.
Slide 66
#1: A150
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
The facility did not comply with state requirements and
local health ordinances relating to Texas food
establishments.
Examples of conditions that might be cited include the
following:
• Freezer with opened, undated frozen packages of
pancakes and biscuits.
• Refrigerator contained undated, unsealed food items and
did not have "opened on" dates.
• Food storage pantry with food cases stored directly on the
floor.
Slide 67
#1: A150 Example of a Citation
§98.43(b)(1) Sanitation/Kitchen−Food Service Sanitation
Based on observations and interview the facility failed to follow
the Texas Food Establishment Rules on kitchen sanitation.
The findings were:
Inspector observed on 04/04/15 at 9:30 a.m. the following:
• two bags of opened corn chips not dated or labeled; and
• two bags of raw meat left to thaw on the kitchen counter (the
meat was not submerged in water).
Interview on 04/04/15 at 9:45 a.m. with Cook A revealed she was
aware of the dating and labeling rule.
These failures could place all 36 clients at risk for food borne
illnesses.
Slide 68
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The sanitation in the kitchen refers to the source of the food
obtained by the facility and all of the safety factors involved in
the handling of the food.
true
false
Slide 69
Activity: True/False
True is the correct answer.
The sanitation in the kitchen refers to the source of the food
obtained by the facility and all of the safety factors involved
in handling of the food.
Slide 70
Correcting Deficient Practices
The facility needs to:
• Analyze the problem by asking what happened and
identify the root cause;
• Address the problem by developing and implementing a
Plan of Correction; and
• Improve policies and procedures within systems to ensure
lasting consistent compliance.
Slide 71
Conclusion
These Top 10 violations tend to remain on Top 10 lists
because they involve key facility systems, such as food
service, maintenance, abuse prevention, staff
responsibilities, personal safety and emergency
preparedness. These are areas that involve the interaction
of many different staff in multiple departments.
The expectation is the facility will analyze the problem with
the goal of developing a solution that is sustainable. This
requires the facility to understand the cause of the problem
and whether the problem is linked to a failure in the
facility’s system(s).
Slide 72
Conclusion (continued)
The facility can devise an appropriate and lasting solution
to correct any existing or potential problems.
Substantial compliance can be achieved and maintained by
understanding deficient practices and implementing the
rules.
The facility must consistently monitor its practices and
make adjustments as necessary.
Slide 73
DADS Websites
This is DADS home page—
www.dads.state.tx.us
DADS provides joint trainings. The Joint Training website
contains the current schedule and a description of each
course. These courses provide continuing education for
some disciplines.
Joint Training Seminars—
www.dads.state.tx.us/providers/training/jointtraining.cfm
Slide 74
Contact
If you have questions or need additional information,
contact:
DADS Regulatory Services
Policy, Rules and Curriculum Development
512-438-3161
Ask for an DAHS program specialist.