Adult Family Care Home Top Ten Health Deficiency Citations Statewide January 7, 2018 Year Date Range: July 1, 2016 through June 30, 2017
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1 Adult Family Care Home Top Ten Health Deficiency Citations 1 F Freedom From Communicable Disease (58A (2)(a)1, 58A (1)(a)) 2 Z Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 3 F Health Assessment Requirement (58A (2)) 4 F Resident Records Standards (58A (1)a) 5 F Staff Training (58A (4)(d)) 6 F Medication: Assistance & Administration (58A (1)(b)(1, 2, 4, & 6)) 7 F Staff First Aid And CPR (58A (4)(c)) 8 F Residency Agreement (58A (2-3)) 9 Z Background Screening; Prohibited Offenses ( ; (2); F.S.) 10 F Admission/discharge Records (58A (3)(f))
2 Ambulatory Surgical Center Top Ten State Life Safety Deficiency Citations 1 K Electrical Safety (NFPA LSC; NFPA ; NFPA 9) 2 K Generator Maintenance & Testing (NFPA LSC; NFPA ) 3 K Fire Alarm Testing (NFPA LSC) 4 K AFSS & Standpipe-Inspect, Test, & Maintain (NFPA LSC) 5 K Emergency Lighting (NFPA LSC; NFPA ) 6 K Medical Gas-Piped In (NFPA LSC; NFPA 99 (2012)) 7 K Generator - Fuel Testing (NFPA LSC; NFPA ) 8 K Firestop Systems And Devices (NFPA LSC) 9 K Emergency Management Plan (59A F.A.C.) 10 K Fire Alarm (NFPA LSC)
3 Assisted Living Facility Top Ten Health Deficiency Citations 1 Z Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 2 A Staffing Standards - Staff (58A-5.019(2) F.A.C.) 3 A Resident Care - Rights & Facility Procedures (58A (6) F.A.C.; (1-2) F.S.) 4 A Training - Staff In-Service (58A (2) F.A.C.) 5 A Food Service - Dietary Standards (58A-5.020(2) F.A.C.) 6 A Admissions - Continued Residency (429.26(1&9) F.S.; 58A (4) F.A.C.) 7 A Physical Plant - Safe Living Environ/other (58A-5.023(3) F.A.C.) 8 A Resident Care - Supervision (429.26(7) F.S.; 58A (1) F.A.C.) 9 A Staffing Standards - Levels (58A-5.019(3) F.A.C.) 10 A Medication - Assistance With Self-Admin (58A (3))
4 Birthing Centers Top Ten State Life Safety Deficiency Citations 1 K Fire Plan/drills/local Ahj Insp/fire Ext Svc (59A-11, F.A.C.) 2 K Emergency Lighting (NFPA LSC) 3 K Disaster Plan (59A-11, F.A.C.) 4 K Egress Signage (NFPA LSC) 5 K Fire Extinguishers (NFPA LSC) 6 K Automatic Fire Sprinkler System (NFPA LSC) 7 K Oxygen Safety (59A-11, F.A.C.) 8 K Fire Alarm (NFPA LSC) 9 K Utilities (NFPA LSC) 10 K Extinguisher Training (NFPA LSC) 11 K Physical Environment & Water Supply (59A-11, F.A.C.)
5 Health Care Clinics Top Ten Health Deficiency Citations 1 U Clinic Responsibilities-Systematic Bill Rvw ( (1)(g), F.S., 59A (3)(m)) 2 U Clinic Responsibilities-Med Dir Oversight (59A (3)(i), F.A.C.) 3 U Clinic Responsibilities-Record Sign Off (59A (3)(q), F.A.C.) 4 U Clinic Responsibilities-Compliance By Med Dir (59A (3)(s), F.A.C.) 5 U Right Of Inspection; Provider On Site ( (7)(d), F.S.) 6 U Clinic Responsibilities-Organizational Chart (59A (3)(p), F.A.C.) 7 U Clinic Resp-Records, Surgery, Adv Incidents ( (1)(f), F.S., 59A (3)(e-g)) 8 U Clinic Responsibilities-Log Of Level 2 Bkgd Ck (59A (3)(r), F.A.C.) 9 Z815 7 Background Screening; Prohibited Offenses ( ; (2); F.S.) 10 U Clinic Responsibilities-Clinic Records System (59A (3)(d), F.A.C.) 11 U Clinic Responsibilities-Equipment Certified (59A (3)(o), F.A.C.) 12 Z814 6 Background Screening Clearinghouse (435.12(2)(b-d), F.S.)
6 Home Health Agency Top Ten State Health Deficiency Citations 1 H Treatment Orders ( (2), F.S.; 59A (2) F.A.C.) 2 Z Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 3 H Plan Of Care (59A (1), F.A.C.; (2) F.S.) 4 H Personnel - Registered Nurse (59A (3)(a), F.A.C.) 5 H Clinical Records ( (1), F.S.) 6 H Plan Of Care ( (6), F.S.) 7 H Acceptance Of Patients Or Clients (59A-8.020(1) F.A.C.;) 8 H Clinical Records Contents (59A-8.022(5-6), F.A.C.) 9 H Termination Of Services (59A-8.020(4), F.A.C.) 10 H Written Agreement ( (1), F.S.; 59A-8.020(2) F.A.C.)
7 Hospice Top Ten State and Federal Health Deficiency Citations 1 T Plan Of Care ( (5-6), F.S.) 2 T Patient's Medical Record ( (1), F.S.) 3 L Coordination Of Services (418.56(e)(2), C.F.R.)) 4 T Hospice Residential Care ( (3) F.S.) 5 T Staff Training Requirements- Alzheimer's ( (1)(b), F.S., 58A (1)(a), F.A.C.) 6 L Exercise Of Rights/Respect For Property/person (418.52(b)(1), C.F.R.) 7 L Coordination Of Services (418.56(e)(5), C.F.R.) 8 L Clinical Records ( , C.F.R.) 9 T Administrative Policies-Universal Precautions (58A-2.005(3)(a)16, F.A.C.) 10 Z814 4 Background Screening Clearinghouse (435.12(2)(b-d), F.S.)
8 Hospital Top Ten State Health Deficiency Citations 1 H Nursing Service - Care Process (59A (5)(e)1-3, F.A.C.) 2 H Approp Measure - Education & Training ( (1)(b)1, F.S.; 59A (1), F.S.) 3 H Patient Safety Officer And Committee ( (2), F.S.) 4 H Health Information Mgmt - Medical Records (59A-3.270(3), F.A.C.; (6), F.S.) 5 H Patient Rights & Care - Coord Of Care (59A-3.254(2) F.A.C.) 6 H Patient Rights & Care - Add'l Policy/procedure (59A-3.254(4)(c)-(h) and (5), F.A.C.) 7 H Incident Reporting System - Reports (59A (2)(c)-(e), F.A.C.) 8 H Maintenance - Preventive Plan (59A-3.276(1)(a)-(g), F.A.C.) 9 H RM Prog - Incident Reporting System ( (1)(e) F.S.; 59A (2)(ab), F.A.C.) 10 H Emergency Care - Emergency Services Personnel (59A-3.255(6)(a)1, F.A.C.;)
9 Hospital Top Ten State Life Safety Deficiency Citations 1 K AFSS & Standpipe-Inspect, Test, & Maintain (NFPA LSC) 2 K Electrical Safety (NFPA LSC) 3 K Cooking Equipment ( NFPA LSC) 4 K Medical Gas ( NFPA LSC) 5 K Corridor Doors (NFPA LSC) 6 K Generator Maintenance & Testing (NFPA LSC, NFPA ) 7 K Firestop Systems And Devices (NFPA LSC) 8 K Fire Alarm Testing ( NFPA LSC) 9 K Emergency Management Plan (59A-3.078, F.A.C.) 10 K Portable Space Heaters ( NFPA LSC) 11 K Medical Gas - Piped In ( NFPA LSC)
10 Intermediate Care Facility for the Developmentally Disabled Top Ten Federal Health Deficiency Citations 1 W Program Implementation ( (d)(1), C.F.R.) 2 W Infection Control ( (l)(1), C.F.R.) 3 W QIDP ( (a), C.F.R.) 4 W Drug Administration ( (k)(2), C.F.R.) 5 W Drug Administration ( (k)(1), C.F.R.) 6 W Services Provided With Outside Sources ( (d)(3), C.F.R.) 7 W Staff Training Program ( (e)(1), C.F.R.) 8 W Nursing Services ( (c), C.F.R.) 9 W Active Treatment ( (a)(1), C.F.R.) 10 W Space And Equipment ( (g)(2), C.F.R.)
11 Laboratory Top Ten State and Federal Health Deficiency Citations 1 L Participation In Proficiency Testing (59A-7.025(3)(a), F.A.C.) 2 D Successful Participation ( (a)(b)(c), C.F.R.) 3 L General Quality Control Requirements (59A-7.029(1), F.A.C.) 4 L Quality Assurance (59A-7.031(7), F.A.C.) 5 D Evaluation Of Proficiency Testing Performance ( (c)(1), C.F.R.) 6 D Moderate Complexity Laboratory Director ( , C.F.R.) 7 D Laboratory Director Responsibilities ( (e)(4)(i), C.F.R.) 8 D Personnel Competency Assessment Policies ( ) 9 L Quality Assurance (59A-7.031(1), F.A.C.) 10 L Quality Assurance (59A-7.031(5)(b), F.A.C.)
12 Nurse Registry Top Ten State and Federal Health Deficiency Citations 1 G Communicable Disease (59A (6) F.A.C.; (6)(a) F.S.) 2 G C.N.A. & Home Health Aide - Physician ( (6)(b), F.S) 3 Z Background Screening Clearinghouse (435.12(2)(b-d), F.S.) 4 G Emergency Management Plan Updates ( (12), F.S.; 59A (2-3) F.A.C.) 5 Z Background Screening; Prohibited Offenses ( ; (2); F.S.) 6 G Contractor Registration Folders (59A (7-8) F.A.C.; (8-10) F.S.) 7 G C.N.A. & Home Health Aide - CPR (59A (11), F.A.C.) 8 Z Background Screening-Compliance Attestation ( (2)(a-c) F.S.) 9 G Hours Of Operation (59A (9), F.A.C.) 10 G HH Aide Qualifications (59A (8 & 10 & 12-13), F.A.C.)
13 Nursing Home Top Ten Federal Health Deficiency Citations 1 F Infection Control, Prevent Spread, Linens (483.80(a)(1)(2)(4)(e)(f), C.F.R.) 2 F Food Procure, Store/prepare/serve - Sanitary (483.60(i)(1)-(3), C.F.R.) 3 F Services By Qualified Persons/per Care Plan (483.21(b)(3)(ii), C.F.R.) 4 F Drug Records, Label/store Drugs & Biologicals (483.45(b)(2)(3)(g)(h), C.F.R.) 5 F Housekeeping & Maintenance Services (483.10(i)(2), C.F.R.) 6 F Provide Care/services For Highest Well Being (483.24, (k)(l), C.F.R.) 7 F Res Records-Complete/accurate/accessible (483.70(i)(1)(5), C.F.R.) 8 F Free Of Accident Hazards/supervision/devices (483.25(d)(1)(2)(n)(1)-(3), C.F.R.) 9 F Dignity And Respect Of Individuality (483.10(a)(1), C.F.R.) 10 F Develop Comprehensive Care Plans (483.20(d);483.21(b)(1), C.F.R.)
14 Nursing Home Top Ten State Life Safety Deficiency Citations 1 K AFSS & Standpipe-Inspect, Test, & Maintain ( NFPA 101- LSC 2012) 2 K Electrical Safety (NFPA 101-LSC2012,NFPA70-11NFPA99-) 3 K Firestop Systems And Devices (NFPA LSC) 4 K Corridor Doors (NFPA 101- LSC 2012) 5 K Cooking Equipment ( NFPA 101- LSC 2012) 6 K Medical Gas (NFPA 101- LSC 2012) 7 K Fire Alarm Testing ( NFPA 101- LSC 2012, NFPA ) 8 K Generator Maintenance & Testing (NFPA LSC, NFPA ) 9 K HVAC Equipment (NFPA 101- LSC 2009) 10 K Smoking Regulations ( NFPA 101- LSC 2012)
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