Adult Family Care Home Top Ten Health Deficiency Citations...

Note: The entire description of each deficiency can be found at http://ahca.myflorida.com/MCHQ/Current_Regs.shtml

Adult Family Care Home

Top Ten Health Deficiency Citations

Statewide

March 27, 2019

Year Date Range: July 1, 2017 through June 30, 2018

Rank Tag Count Description

1 F0401 69 Freedom From Communicable Disease (58A-14.0085(2)(a)1, 58A-14.008(1)(a))

2 F0606 47 Staff Training (58A-14.008(4)(d)) 3 F0512 46 Health Assessment Requirement (58A-14.0061(2))

4 Z814 35 Background Screening Clearinghouse (435.12(2)(b-d), F.S.)

5 F0605 31 Staff First Aid And CPR (58A-14.008(4)(c)) 6 F0700 28 Medication: Assistance & Administration (58A-14.007(1)(b)(1, 2, 4, & 6))

7 F0602 27 Continuing Education (58A-14.008(4)(b)) 8 Z815 23 Background Screening; Prohibited Offenses (408.809; 435.02(2); 435.06 F.S.)

9 F0402 21 Staff Record Requirements - Training, Document (58A-14.0085(2)(a)2-3) 10 Z813 15 Results Of Screening & Notification In File (59A-35.090(3)(c), F.A.C.)

http://ahca.myflorida.com/MCHQ/Current_Regs.shtml


Ambulatory Surgical Center

Top Ten State Life Safety Deficiency Citations

Statewide

March 27, 2019



1 K0345 73 Fire Alarm System - Testing And Maintenance (NFPA 101) 2 K0918 52 Electrical Systems - Essential Electric System (NFPA 99)

3 K0353 48 Sprinkler System - Maintenance And Testing (NFPA 101)

4 K0291 34 Emergency Lighting (NFPA 101) 5 K1053 23 Emergency Management Plan (F.A.C. 59A-3.078)

6 K0923 22 Gas Equipment - Cylinder And Container Storage (NFPA 99) 7 K0914 18 Electrical Systems - Maintenance And Testing (NFPA 99)

8 K0521 14 HVAC (NFPA 101) 9 K0712 14 Fire Drills (NFPA 101)

10 K0913 13 Electrical Systems - Wet Procedure Locations (NFPA 99)



Assisted Living Facility


Statewide

March 27, 2019



1 A0078 501 Staffing Standards - Staff (58A-5.019(2) F.A.C.)

2 Z814 452 Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 3 A0162 416 Records - Resident (58A-5.024(3) F.A.C.)

4 A0030 389 Resident Care - Rights & Facility Procedures (58A-5.0182(6) F.A.C.; 429.28(1-2) F.S.)

5 A0081 343 Training - Staff In-Service (58A-5.0191(2) F.A.C.)

6 A0152 326 Physical Plant - Safe Living Environment/Other (58A-5.023(3) F.A.C.) 7 A0181 319 Emergency Plan Approval (58A-5.026(2) F.A.C.)

8 A0052 304 Medication - Assistance With Self-Administration (58A-5.0185 (3)) 9 A0093 304 Food Service - Dietary Standards (58A-5.020(2) F.A.C.)

10 A0008 302 Admissions - Health Assessment (429.26(4-6) F.S.; 58A-5.0181(2) F.A.C.)



Birthing Centers


Statewide

March 27, 2019



1 K1029 7 Fire Plan/Drills/Local AHJ Insp/fire Ext Svc (F.A.C. 59A-11)

2 K1007 4 Emergency Lighting (NFPA 101-2012 LSC) 3 K1026 4 Disaster Plan (F.A.C. 59A-11)

4 K1028 4 Oxygen Safety (F.A.C. 59A-11)

5 K1013 3 Fire Alarm (NFPA 101-2012 LSC) 6 K1030 3 Physical Environment & Water Supply (F.A.C. 59A-11)

7 K1008 2 Egress Signage (NFPA 101-2012 LSC) 8 K1014 2 Fire Extinguishers (NFPA 101-2012 LSC)

9 K1023 2 Maintenance, Inspection, And Testing (NFPA 101-2012 LSC) 10 K0308 1 Egress Signage (NFPA 101-2012 LSC)

11 K1010 1 Hazardous Areas (NFPA 101-2012 LSC)

12 K1015 1 Utilities (NFPA 101-2012 LSC) 13 K1021 1 Automatic Fire Sprinkler System (NFPA 101-2012 LSC)

14 K1032 1 Other Standards Not Previously Listed



Health Care Clinics


Statewide

March 27, 2019



1 U0335 53 Clinic Responsibilities-Systematic Bill Review (400.9935(1)(g), F.S., 59A-33.012(3)(m))

2 U0345 34 Clinic Responsibilities-Medical Director Oversight (59A-33.012(3)(i), F.A.C.)

3 U0350 29 Clinic Responsibilities-Compliance By Medical Director (59A-33.012(3)(s), F.A.C.)

4 U0340 25 Clinic Responsibilities-Record Sign Off (59A-33.012(3)(q), F.A.C.) 5 Z815 13 Background Screening; Prohibited Offenses (408.809; 435.02(2); 435.06 F.S.)

6 U0319 12 Clinic Responsibilities - Personnel File (59A-33.012(3)(h))

7 U0326 12 Clinic Responsibilities-Clinic Records System (59A-33.012(3)(d), F.A.C.) 8 U0330 12 Clinic Responsibilities-Records, Surgery, Adverse Incidents (400.9935(1)(f),

F.S., 59A-33.012(3)(e-g)) 9 U0155 11 Notice Of Insurance Fraud Display (400.9935(9), F.S.)

10 U0342 11 Clinic Responsibilities-Equipment Certified (59A-33.012(3)(o), F.A.C.)



Home Health Agency

Top Ten State Health Deficiency Citations

Statewide

March 27, 2019



1 H0302 65 Treatment Orders (400.487(2), F.S.; 59A-8.0215(2) F.A.C.)

2 Z814 57 Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 3 H0320 40 Plan Of Care (59A-8.0215(1), F.A.C.; 400.487(2) F.S.)

4 H0350 37 Clinical Records (400.491(1), F.S.)

5 H0356 33 Clinical Records Contents (59A-8.022(5-6), F.A.C.) 6 H0304 32 Written Agreement (400.487(1), F.S.; 59A-8.020(2) F.A.C.)

7 H0376 30 Emergency Management Plan Review (400.497(8); 400.492(1); 59A-8.027(2-3))

8 H0230 29 Personnel - Registered Nurse (59A-8.0095(3)(a), F.A.C.) 9 H0315 27 Acceptance Of Patients Or Clients (59A-8.020(1) F.A.C.; )

10 Z816 26 Background Screening-compliance Attestation (408.809(2)(a-c) F.S.) 11 Z818 26 Minimum Licensure Requirement - Client Notice (408.810(5) F.S.)



Hospice

Top Ten State and Federal Health Deficiency Citations

Statewide

March 27, 2019



1 T0061 9 Plan Of Care (400.6095(5-6))

2 L0591 7 Nursing Services (418.64(b)(1)) 3 K0345 7 Fire Alarm System - Testing And Maintenance (NFPA 101)

4 K0918 6 Electrical Systems - Essential Electric System (NFPA 101)

5 K0353 5 Sprinkler System - Maintenance And Testing (NFPA 101) 6 T0096 5 Patient's Medical Record (400.611(1))

7 K0918 4 Electrical Systems - Essential Electric System (NFPA 101) 8 L0505 4 Exercise Of Rights/Respect For Property/Person (418.52(b)(1))

9 K0921 4 Electrical Equipment - Testing And Maintenance (NFPA 101)



Hospital

Top Ten State Health Deficiency Citations

Statewide

March 27, 2019



1 H0120 26 Nursing Service - Care Process (59A-3.2085(5)(e)1-3, F.A.C.)

2 H0119 20 Nursing Service-Standard Of Practice & Policy/Procedures (59A-3.2085(5)(d), F.A.C.)

3 H0029 18 Patient Rights & Care – Additional Policy/Procedures (59A-3.254(4)(c)-(h) and (5) F.A.C.)

4 H0416 17 15 Day Reports (395.0197(5 &7) F.S.; 59A-10.002(5) F.A.C.) 5 H0410 15 RM Program - Incident Reporting System (395.0197(1)(e) F.S.; 59A-

10.0055(2)(a-b)) 6 H0199 14 Surveil/Prevention/Control Of Infection- Program (59A-3.250(1)F.A.C.)

7 H0426 14 Patient Safety Officer And Committee (395.1012(2), F.S.)

8 H0076 13 Nutritional Care - Environment & Equipment (59A-3.2085(1)(j)-(p), F.A.C.) 9 H0409 11 RM Program - Pt Notification Of Adverse Incidents (395.0197 (1)(d), 395.1051

F.S.) 10 H0022 10 Patient Rights & Care - Coordination Of Care (59A-3.254(2) F.A.C.)



Hospital


Statewide

March 27, 2019



1 K0353 41 Sprinkler System - Maintenance And Testing (NFPA 101)

2 K0923 40 Gas Equipment - Cylinder And Container Storage (NFPA 99) 3 K0920 38 Electrical Equipment - Power Cords And Extensions (NFPA 99)

4 K0918 35 Electrical Systems - Essential Electric System (NFPA 99)

5 K0345 32 Fire Alarm System - Testing And Maintenance (NFPA 101) 6 K0914 29 Electrical Systems - Maintenance And Testing (NFPA 99)

7 K0324 25 Cooking Facilities (NFPA 101) 8 K0363 24 Corridor - Doors (NFPA 101)

9 K0211 20 Means Of Egress - General (NFPA 101) 10 K0291 18 Emergency Lighting (NFPA 101)

11 K0351 18 Sprinkler System - Installation (NFPA 101)



Intermediate Care Facility for the Developmentally Disabled

Top Ten Federal Health Deficiency Citations

Statewide

March 27, 2019



1 W0249 31 Program Implementation (483.440(d)(1))

2 W0189 20 Staff Training Program (483.430(e)(1)) 3 W0454 20 Infection Control (483.470(l)(1))

4 W0124 18 Protection Of Clients Rights (483.420(a)(2))

5 W0159 16 QIDP (483.430(a)) 6 W0154 15 Staff Treatment Of Clients (483.420(d)(3))

7 W0331 15 Nursing Services (483.460(c)) 8 W0369 15 Drug Administration (483.460(k)(2))

9 W0196 10 Active Treatment (483.440(a)(1)) 10 W0102 9 Governing Body And Management (483.410)



Laboratory


Statewide

March 27, 2019



1 D5413 43 Test Systems, Equipment, Instruments, Reagent (493.1252(b))

2 D5209 37 Personnel Competency Assessment Policies (493.1235) 3 D2016 35 Successful Participation (493.803(a)(b)(c))

4 D6000 27 Moderate Complexity Laboratory Director (493.1403)

5 D5217 25 Evaluation Of Proficiency Testing Performance (493.1236(c)(1)) 6 D6016 24 Laboratory Director Responsibilities (493.1407(e)(4)(i))

7 D5417 17 Test Systems, Equipment, Instruments, Reagent (493.1252(d)) 8 D2131 16 Hematology (493.851(g))

9 D3011 15 Facilities (493.1101(d)) 10 D5407 14 Procedure Manual (493.1251(d))

11 D5791 14 Analytic Systems Quality Assessment (493.1289(a)(c))



Nurse Registry


Statewide

March 27, 2019



1 Z814 40 Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 2 G0275 35 C.N.A. & Home Health Aide - Physician (400.506(6)(b), F.S)

3 G0151 32 Communicable Disease (59A-18.005(6) F.A.C.; 400.506(6)(a) F.S.) 4 G0292 27 Emergency Management Plan Updates (400.506(12), F.S.; 59A-18.018(2-3)

F.A.C.) 5 G0272 18 C.N.A. & Home Health Aide - CPR (59A-18.0081(11), F.A.C.)

6 G0291 16 Emergency Management Plan (400.506(12) F.S.; 59A-18.018(1) F.A.C.)

7 Z815 15 Background Screening; Prohibited Offenses (408.809; 435.02(2); 435.06 F.S.) 8 G0160 14 Administrator (400.506(18); 408.803(7); 59A-18.006)

9 G0273 13 Evidence Of HIV Training (400.506(8)(e), F.S.) 10 G0152 12 Contractor Registration Folders (59A-18.005(7-8) F.A.C.; 400.506(8-10) F.S.)



Nursing Home


Statewide

March 27, 2019



1 F0880 199 Infection Prevention & Control (483.80(a)(1)(2)(4)(e)(f))

2 F0441 148 Infection Control, Prevent Spread, Linens (483.80(a)(1)(2)(4)(e)(f))

3 F0656 132 Develop/Implement Comprehensive Care Plan (483.21(b)(1)) 4 F0812 119 Food Procurement, Store/Prepare/Serve-Sanitary (483.60(i)(1)(2))

5 F0371 108 Food Procure, Store/Prepare/Serve - Sanitary (483.60(i)(1)-(3)) 6 F0761 100 Label/Store Drugs And Biologicals (483.45(g)(h)(1)(2))

7 F0253 94 Housekeeping & Maintenance Services (483.10(i)(2)) 8 F0431 94 Drug Records, Label/Store Drugs & Biologicals (483.45(b)(2)(3)(g)(h))

9 F0282 93 Services By Qualified Persons/Per Care Plan (483.21(b)(3)(ii))

10 F0684 85 Quality Of Care (483.25)



Nursing Home


Statewide

March 27, 2019



1 K0345 156 Fire Alarm System - Testing And Maintenance (NFPA 101) 2 K0353 142 Sprinkler System - Maintenance And Testing (NFPA 101)

3 K0918 118 Electrical Systems - Essential Electric Systems (NFPA 99) 4 K0923 80 Gas Equipment - Cylinder And Container Storage (NFPA 99)

5 K0363 64 Corridor - Doors (NFPA 101)

6 K0324 52 Cooking Facilities (NFPA 101) 7 K0920 51 Electrical Equipment - Power Cords And Extensions (NFPA 99)

8 K0521 49 HVAC (NFPA 101) 9 K1011 48 Fire Doors (NFPA 101)

10 K1053 47 Emergency Management Plan (F.A.C. 59A-4.126)


Adult Family Care Home Top Ten Health Deficiency Citations...

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