Do This, Not ThatAvoiding the Most Common

DHEC Health Licensing Violations

PTH SolutionsSeptember 28, 2015

Regulation 61.184 Standards for Licensing Community Residential Care Facilities (CRCFs)

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Why?

Last 15 months:

23 of 33 enforcement actions (70%) were against CRCFs (unusually low because of midwife actions) – Average 1.5 enforcement actions against CRCFs EVERY month

Results were 2 revocations, $196,400 in assessed penalties ($72,900 in collected penalties)

DHEC Inspections

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DHEC Inspectors

Profile

Case Load:

472 CRCFs with 17,448 beds

1,889 facilities with 65,168 beds/stations

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A day in the life of an inspector

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Inspections

Be Prepared

Be Organized

Be Efficient

Snapshot in Time

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Types of Inspections

Initial

General/Comprehensive

Kitchen, 61.25

Complaint

Follow-Up

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Initial Inspection

Announced

"Turn Key“ – ready to go

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General/Comprehensive Inspection

Unannounced

Patterns

Look at everything

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Kitchen Inspection

Unannounced

Yearly

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Complaint Inspection

Unannounced

Triaged

Specific Issues

Anonymous

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Follow-up Inspection

Unannounced

Rare

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Things to Consider

Internal QA

Checklists and Audits

Outside Review

Staff Training

Policies

Designated Staff

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Most Common Violations

#1 - Food Service

#2 - Medications

#3 – Others: Resident Records, General Cleanliness

Food Service

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Risk based inspections and processe

Kitchen Inspections

Risk based inspections and processes

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Most Common Kitchen Violation

Storage, cleaning and sanitizing of equipment and utensils in accordance with R.61-25.• Frequency of cleaning • Method of cleaning and sanitizing• Sanitizing after cleaning• Storage

R.61-25, Sections 4-6, 4-7, and 4-9

*Most often cited violation

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Preventing Other Common Kitchen Violations

Equipment, food and non-food contact surfaces:

• approved

• cleanable

• properly designed, constructed and used

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Equipment, Food Contact Surfaces, Non-food Contact Surfaces and Utensils

• Clean to sight and touch

• No encrusted grease or soil accumulation on pans on food contact surfaces

• No dust, dirt, food residue, or other debris on non food contact surfaces

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Sanitization

Must sanitize equipment food-contact surfaces and utensils

Clean then sanitize utensils and equipment food-contact surfaces

Hot water, chemical, manual and mechanical methods for sanitization

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Drying and Storage

Air dry equipment and utensils

Wiping cloths – Air dry or specified clothes dryer – may launder and sanitize instead

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Cleaning of Surfaces

Food Contact Surfaces :

Smooth, free of breaks, chips, pits, cracks, etc.

Cleanable without disassembly, disassembly without tools or with common tools only

Non-food Contact Surfaces:

Free of unnecessary ledges, projections, and crevices

Designed and constructed to allow easy cleaning and to facilitate maintenance

Medications

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Administration

Administer medications in accordance with orders of the attending physician, dentist or other legally authorized person. Pay attention to dose, frequency, etc. No current order=no meds #2 cited violation

Remove the dose from properly labeled container, verify the dosage on physician’s order, give to proper patient, monitor the ingestion, promptly record on MAR the specific info

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Administration – continued

If med not available (out of stock) cannot “borrow” from another patient

Do not administer expired medications

Never have another staff member “pull” meds for you to administer

Pay special attention to label/MARs noted “dosage change”

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Administration – continued

Residents going on leave from facility must have

medications properly packaged and labeled for lay

person’s understanding and placed in container

offering proper security; when controlled

substances will be surrendered to family, etc, it may

be advisable to have them sign acknowledgement of

receipt; also properly document absence on MAR

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Administration – continued

Do not document administration prior to med pass

Resident in dining room-never leave med at bedside/room-must observe consumption

Clarify number of doses administered when ordered as 1-2 tablets

Properly document refused/wasted meds

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Securing and Storing Medications

Upon receipt from pharmacy – immediately secure controlled substances in approved locations and conditionsVerify accurate count upon receipt and verify match on MAR/physician’s order – do not rely on pharmacy label for administration instructionsMaintain records of receipt in sufficient detail to enable accurate reconciliation

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Ordering Medications

Verbal orders are allowed by authorized personnel

Obtain authentication per policies and procedures – no later than 3 days

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Storage/Access to Drugs

Allow access/give keys only to authorized parties – Do not loan keys to unauthorized personnel

Keep med cart locked at all times, even during med pass

Controlled substances must be stored in separate locked, permanently affixed, compartments within a locked medicine prep room, cabinet or med cart

Meds should be stored under proper conditions of sanitation, temp, light, moisture, ventilation, segregation, safety & security; separate from poisonous substances; separate topical from oral

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Accountability & Controlled Substances

Have separate med control for controlled substances. Establish a mechanism to be assured all controlled substances are counted each shift. If count sheet and drug removed, would you realize it was missing?

If surplus unused drug cards stored in med room (inadequate cart space) establish mechanism to count those also.

Note each card for contents, evidence of tampering-separate each card and visually review front and back (this includes “surplus” stock)

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Accountability & Controlled Substances(Continued)

Conduct counts with minimal interruptions to avoid distractions/errors/omissions

Do not sign-off on counts if you have concerns or questions or have not personally verified such

Establish policy and procedure for handling count discrepancies

Maintain records of receipt, administration, and disposition of meds to enable accurate reconciliation

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Medication Disposal

Remove supply upon discontinuation of order or patient

Properly secure in designated location

Verify counts at time of removal from cart

Destruction should occur per policies and procedures –witnessed by administrator or designee and trained staff member – talk to pharmacy

Maintain records of destruction

Other Common Violations

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Resident Records

Records must show that the needs of the resident are being met. Done through records of:• Provision or arrangement of care/services as

needed• Notes on symptoms of sickness or injury• Monitoring of physical/mental condition• Response/reaction to medication• Diet provided• Acceptable standards of practice

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Resident Records – continued

Specific documentation required:

• ICP• Physician consultations• Orders for meds, services, procedures, diet, etc.• Care/services such as hospice or home health• Medications administered• Special procedures• Notes of observation• Discharge, transfer, or death• Routine and emergency medical care• Special info such as DNR, allergies, POA, etc.• Photograph

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Cleanliness & Housekeeping

Facility and grounds clean, free of vermin and offensive odors.

Interior housekeeping:

• Cleaning each area

• Cleaning & disinfecting equipment

• Safe storage of chemicals

Exterior housekeeping:

• Cleaning of exterior, including ramps, porches, etc.

• Keep grounds free of weeds, overgrown landscaping, etc

• Safe storage of chemicals

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Inspection Reports, Citations, and Enforcement Actions

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Inspection Reports

Snapshot of the day

Exit and signing the report

Request for Consideration of Cited Violations

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Classification of Violations – Class I

Class I – Imminent danger to health and safety, or substantial probability that death or serious physical harm could result from the violation. A physical condition or one or more practices, means, methods, or operations in a facility may constitute a violation.

Must be abated or eliminated immediately unless a period of time is stipulated by DHEC.

If DHEC specifies a specific time for correction, each day of violation after that is considered a subsequent violation.

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Class I violation examples:

Insufficient staffing

Staff: Failure to train/document training for staff, health status, background checks

Failure to provide care/services to residents

Failure to follow physician’s orders for residents

Physical exams for residents prior to admission and annually thereafter

Medication management violations

Level of care violations

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Classification of Violations – Class II

Class II – DHEC determines violation has a negative impact on the health, safety, and well-being of persons in the facility.

DHEC may specify a time within which the violation is to be corrected. If so, each day of violation after that is considered a subsequent violation.

Examples: policies and procedures, reporting of accidents/incidents, resident records, resident rights and assurances, meal service personnel, disaster preparedness

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Classification of Violations – Class III

Class III – Not Class I or Class II, or those that are against best practices as interpreted by DHEC. In other words, everything else!

DHEC may specify a time within which the violation is to be corrected. If so, each day of violation after that is considered a subsequent violation.

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Determining Classification of Violations

Notation in regulation:

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Enforcement Actions

DHEC considers:

Number and classification of violations, including repeat violations

Specific conditions and impact or potential impact on health and safety of residents

Efforts by the facility to correct violations

Overall conditions of the facility

Compliance history

Any other pertinent conditions

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Enforcement Actions

May be a monetary penalty, based upon class of violation and repeat violations

May include suspension of license (cannot admit or readmit residents)

Questions?

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How we can help:

Mock Inspections

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Responding to DHEC inspection

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Pam Dukes Doug Calvert803.730.3862 803.783.7105