Incomplete Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure a comprehensive facility-wide assessment was conducted and documented to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, last completed in August 2024 and reviewed in September 2023, lacked a detailed staffing plan that specified the number of staff required per unit or shift. During a survey conducted in November 2024, it was found that the assessment did not include individual staff assignments or systems for coordination and continuity of care. The Administrator, who had been working at the facility since mid-August 2024, acknowledged the omission and stated that completing the facility assessment was a new task for them.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 The facility assessment was updated to include an updated staffing plan, the requirements of number of staff allotted for each unit or per shift. Plan for system changes and measures to prevent recurrence: The facility assessment’s staffing plan will be reviewed on a quarterly basis to review what changes need to be made to the staffing plan. Any updates/changes and initiatives will be reviewed. Additional input will be requested from the team to see what other suggestions and ideas they might have. Plan for monitoring corrective action: Facility assessment will be reviewed on a quarterly basis and any changes/updates will be discussed at the QA meeting.