Complaints and Deficiencies FY 2013

Note: Fiscal year (FY) 2013 began Sept. 1, 2012, and ended Aug. 31, 2013. Source: Texas Department of Aging and Disability Services Regulatory Services Fiscal Year 2013 Annual Report.

Top 10 Most Frequent Complaint Intake Reasons

  1. Neglect — Failure to provide services, treatment or care that causes or could cause mental or physical injury, or harm or death to the resident. (Ranked No. 1 in fiscal year 2012)

  2. Resident Rights/Client Protections — Failure to ensure that residents have as much autonomy and choice as possible about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. (Ranked No. 2 in fiscal year 2012)

  3. Medications — Failure to properly supervise residents' medication regimen so as to ensure that medications are administered and doses are not missed; or, failure to ensure that unlicensed facility staff delegated to administer residents' medications have proper training and competency to perform this task. (Ranked No. 3 in fiscal year 2012)

  4. Environment — Failure to provide safe and clean living areas with everything in proper working order. (Ranked No. 4 in fiscal year 2012)

  5. Dietary Services — Failure to provide at least three meals or their equivalent daily at regular times, or therapeutic diets as ordered by the resident's physician, and to prepare and serve food utilizing acceptable food handling procedures. (Ranked No. 6 in fiscal year 2012)

  6. Administration — Failure to organize and supervise facility operations to create a safe environment and to meet the needs of individuals. (Ranked No. 5 in fiscal year 2012)

  7. Compliance with Federal, State and Local Laws — Failure of facility staff to comply with state and local laws. (Ranked No. 8 in fiscal year 2012)

  8. Sufficient Staff — Failure to have sufficient numbers of qualified and trained staff to provide residents the kind and amount of supervision and care to ensure their health and safety and to meet their basic needs. (Ranked No.10 in fiscal year 2012)

  9. Abuse, Verbal/Mental — Failure to prevent staff use of oral, written or gestured language that causes an individual psychological harm or trauma. (Ranked No. 7 in fiscal year 2012) [TIE]

  10. Admission, Transfer and Discharge — Failure to assure at the time of admission that a resident is appropriate for placement in the assisted living facility and that the facility is capable of meeting the resident's needs; or, failure to provide a resident proper discharge notice. (Ranked No. 9 in fiscal year 2012) [TIE]

Top 10 Deficiencies Cited During Inspections (Licensure Violations)

  1. General Safety − Building in Good Repair: 40 TAC §92.62(i)(2) — The facility failed to ensure that the building was kept in good repair. (Ranked No. 2 in fiscal year 2012)

  2. Sprinkler Systems: 40 TAC §92.62(f )(2) — The facility failed to ensure the required sprinkler system was inspected, tested and maintained in compliance with NFPA 25. (Ranked No. 3 in fiscal year 2012)

  3. Requirement − Conform to '88 ED NFPA 101: A&B CH 21: 40 TAC §92.61(b)(4)(A) — The facility failed to ensure the building and structure conformed with the 1988 edition of the Life Safety Code, NFPA 101. (Ranked No. 1 in fiscal year 2012)

  4. Requirement − Other Chapters, Sec etc, of NFPA 101: 40 TAC §92.61(b)(4)(C) — The facility failed to ensure the building and structure conformed with other applicable chapters of the Life Safety Code, NFPA 101. (Ranked No. 8 in fiscal year 2012)

  5. FA-SS − Fire Alarm and Sprinkler Systems: 40 TAC §92.62(f )(1) — The facility failed to ensure that the fire alarm and smoke detection system was in compliance with licensing standards for assisted living facilities. (Ranked No. 5 in fiscal year 2012)

  6. Operations: Fire Drills: 40 TAC §92.62(c)(2) — The facility failed to ensure fire drills were conducted and documented to be in compliance with licensing standards for assisted living facilities. (Not ranked in fiscal year 2012)

  7. Sanitation and Housekeeping − Facility Clean and in Good Repair: 40 TAC §92.62(h)(8) — The facility failed to maintain the building free of accumulations of dirt, rubbish, dust and hazards. (Ranked No. 4 in fiscal year 2012)

  8. Construction − Interior Wall and Ceiling Surfaces: 40 TAC §92.62(e)(2) — The facility failed to ensure that interior walls and/or ceilings were constructed with a material having at least a 20-minute fire rating, or at least 3/8 gypsum board. (Ranked No. 10 in fiscal year 2012)

  9. Requirement − Type B Large−Conform to Chapters 21 & 12: 40 TAC §92.61(b)(4)(B) — The facility failed to ensure the building and structure conformed with Chapter 12, New Health Care Occupancies, of the Life Safety Code, NFPA 101. (Ranked No. 6 in fiscal year 2012)

  10. FA-SS − Contract to Maintain Alarm System: 40 TAC §92.62(f )(1)(E) — The facility failed to provide a written contract with a fire alarm firm to perform inspections, testing, and maintenance of the system at least every six months. (Not ranked in fiscal year 2012)

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Updated: September 18, 2014