To improve the quality of life for all South Carolinians by protecting and promoting the health of the public and the environment.
Healthy people living in healthy communities.
Terry English FSO
Grace Lambert MMO
LaTonya Williams Quality Management
Russ Morrison CCO
Katrina Davis Operations & Support
Angie Smith Complaints Management
Katina Roseborough FPP
Community Residential Care Facilities
10 most frequent citations
January 1- July 31, 2017 (Routine Inspections and Investigations) 1. Individual Care Plan=157 2. Physical Examination=80 3. Administering Medications=74 4. Maintenance=71 5. Housekeeping=70
6. Medication Management 7. Following Physician Orders 8. Notes of Observation
9. Medication Management Training 10. Restraint Training The 10 most frequent citations represent 30% of the total or 771 out of 2524 violations.
TOTAL CITED 504. A. 6. 8%
703. A. 20%
504. A. 4 8%
701. B. 6. 8% 1101. A. 10%
901. C. 9%
1203. A. 10%
1201. A. 9% 1703. 9%
1601. 9%
703.A.
Individual Care Plan.
Using the written assessment, the
facility shall develop within seven (7) days of admission an ICP with participation of the resident, administrator (or designee), and/or the sponsor or responsible party when appropriate, as evidenced
by their signatures and date. The ICP shall be reviewed and/or revised as changes in resident needs occur, but not less than semi-annually with the resident, administrator (or designee), and/or the sponsor or responsible party as evidenced by their signatures and date.
• Does the Individual Care Plan (ICP) address: dietary needs, special diet? • Was the ICP signed appropriately? • Does the ICP address advanced directives and/or health care power-of-attorney? • Was the ICP updated every six months or as necessary? • Does the ICP address the needs of the residents, and include interventions? • Does the ICP address special care (allergies , treatments, devices)?
1101.A.
A physical examination shall be completed for residents within thirty (30) days prior to admission and at least annually thereafter. Physical examinations conducted within thirty (30) days prior to admission by physicians licensed in states other than South Carolina are permitted for new admissions under the condition that residents obtain an attending physician licensed in South Carolina within thirty (30) days of admission to the facility and undergo a second (2nd ) physical examination by that physician within thirty (30) days of admission to the facility. The physical examination shall be updated to include new medical information if
the resident’s condition has changed since the last physical examination was completed.
The physical examination addresses:
The appropriateness of placement in a CRCF; Medications/treatments ordered; Self-administration status;
Identification of special conditions/care required, e.g., a communicable disease, dental problems, podiatric problems, Alzheimer’s disease and/or related dementia, etc.; and, The need of (or lack thereof) for the continuous daily attention of a licensed nurse.
1203.A.
Administering Medication/Treatments
Doses of medication shall be administered by the same staff member who prepared them for administration. Preparation shall occur no earlier than one hour prior to administering. Preparation of doses for more than one scheduled administration shall not be permitted. Each physician ordered treatment or
medication dose administered/supervised shall be
properly recorded by initialing on the resident’s medication administration record (MAR) as the medication is administered or treatment record as treatment is rendered.
1203.A. (continued)
Recording medication administration shall
include medication name, dosage, mode of administration, date, time, and the signature of the individual administering or supervising the taking of the medication. If the ordered dosage is to be given on a varying schedule, e.g., “take two tablets the first day and one tablet every other day by mouth with noon meal,� the number of tablets shall also be recorded. The treatment record shall document the type of treatment, date and time of treatment and signature of the individual administering treatment.
A Medication Administration Record (MAR) for each resident.
Doses of medication administered by the same staff member who prepared them for administration. Preparation occurs no earlier than one hour prior to administering.
Each physician ordered treatment or medication dose administered/supervised shall be properly recorded by initialing on the resident’s medication administration record (MAR) as the medication is administered or treatment record as treatment is rendered. Recording medication administration shall include medication name, dosage, mode of administration, date, time, and the signature of the individual administering or supervising the taking of the medication
1601.
all equipment and building components (e.g., doors, windows, lighting fixtures, plumbing fixtures) in good repair and operating condition. The facility shall document preventive maintenance. The facility shall The facility shall keep
comply with the provisions of the codes officially adopted by the South Carolina Building Codes Council and the South Carolina State Fire Marshal applicable to community residential care facilities.
1703.
The facility
and its grounds shall be clean, and free of vermin and offensive odors. (Class II Violation)
1201.A.
Medications, including controlled substances, medical supplies, and those items necessary for the rendering of first aid shall be available and properly managed in accordance with local, State, and Federal laws and regulations. Such management shall address the securing, storing, and administering of medications, medical supplies, first aid supplies, and biologicals, their disposal
when discontinued or outdated, and their disposition at discharge, death, or transfer of a resident. (Class I Violation)
901.C.
The facility shall render
care and services in accordance with orders from physicians or other authorized healthcare providers and take
precautions for residents with special conditions, e.g., pacemakers, wheelchairs, dementia, etc. The facility shall assist in activities of daily living as needed and appropriate. Each facility is required to provide only those activities of daily living and only to the levels specifically designated in the written agreement between the resident, and/or his/her responsible party/guardian, and the facility. (Class I Violation)
701.B.6.
Specific entries/documentation shall include at a minimum:
Notes of observation. In instances that involve significant changes in a resident’s medical condition and/or the occurrence of a serious incident, notes of observation shall be documented at least daily until the condition is stabilized and/or the incident is resolved. In all other instances, notes of observation for residents shall be documented at least monthly; (Class II Violation)
504.A.4.
Documentation of all
inservice training shall be signed and dated by both the individual providing the training and the individual receiving the training.
The following training shall be provided by appropriate resources, e.g., licensed/registered/certified persons, books, electronic media, etc., to all staff members/direct care volunteers and private sitters in the context of their job duties and responsibilities, prior to resident contact and at a frequency determined by the facility, but at least annually unless otherwise specified by certificate, e.g., cardiopulmonary resuscitation
(CPR): 4. Medication
management including storage, administration, receiving orders, securing medications, interactions, and adverse reactions; (Class I Violation)
504.A.6.
Documentation of all
inservice training shall be signed and dated by both the individual providing the training and the individual receiving the training. The following training shall be
provided by appropriate resources, e.g., licensed/registered/certified persons, books, electronic media, etc., to all staff members/direct care volunteers and private sitters in the context of their job duties and responsibilities, prior to resident contact and at a frequency determined by the facility, but at least annually unless otherwise specified by certificate, e.g., cardiopulmonary resuscitation (CPR): 6. Use
techniques; (Class I Violation)
of restraint
• Request for Exception to Licensing Standard
• Request for Reconsideration Form. Both can be found on the website at the following link: http://www.scdhec.gov/Health/FHPF/HealthFa cilityRegulationsLicensing/HealthcareFacilityLi censing/Forms/
• Accident-Incident Reporting Form http://www.scdhec.gov/Health/FHPF/S ubmitAccidentReport/
Facility will submit their Plan of Correction (POC) through the online link found at: http://www.scdhec.gov/Health/FHPF/HealthFacilityReg ulationsLicensing/HealthcareFacilityLicensing/Correcti onPlan/
202. D. When there is noncompliance with the licensing standards, the facility shall submit an acceptable written plan of
correction to the Department that shall be signed by the administrator and returned by the date specified on the report of inspection/investigation. The written plan of correction shall describe: (II) 1. The actions taken to correct each cited deficiency; 2. The actions taken to prevent recurrences (actual and similar); 3. The actual or expected completion dates of those actions.
Enter permit number Enter Captcha Code Click Create Plan of Correction
Inspection Information
• Verify that the prepopulated fields are correct. If not, then go back out and start over. • Enter the Inspection Date • From the drop down menu, choose the Type of Inspection Note: The Inspection Date and the Type of Inspection can be found on the Report of Visit that was given at the end of your inspection.
Administrator’s Certification
•
Check the box to certify you are the administrator
•
Enter information for the administrator
Response to Citations •
Enter the response to citations
•
For multiple citations, click on the plus sign to add additional responses
Upload Documents • Attach supporting documentation • Click to submit
Confirmation •
Once you submit your Plan of Correction, you should receive a confirmation screen with a reference number.
•
Keep this number for your records.
JoMonica Taylor, Support Manager Email: taylorjj@dhec.sc.gov Everette Williams, Support Manager Email: Williael@dhec.sc.gov
Russell Morrison, Director E-mail: morriscr@dhec.sc.gov Kristen Kollu, Field Manager Email: JUAREZKN@dhec.sc.gov Community Care Oversight Division Phone: (803) 545-4370