Deficiency in Facility Staffing Assessment
Penalty
Summary
The facility was cited for not ensuring that their facility assessment included an evaluation of the overall number of staff needed to meet each resident's needs. The Facility Assessment, last updated on October 10, 2024, included a section on staffing plans based on an average daily census of 185 residents. However, this section did not specify any actual staffing minimum numbers. During an interview, the Staffing Coordinator outlined the staffing requirements for different shifts, but these details were not reflected in the Facility Assessment. Additionally, the Administrator acknowledged the challenge of maintaining adequate staffing levels due to a state of emergency regarding the healthcare worker shortage in New York. The Administrator also mentioned the presence of Home Health Aides in the facility, but these aides were not included in the Facility Assessment or staffing assignments. The Administrator admitted to being unaware that the Facility Assessment needed to indicate minimum staffing levels or include Home Health Aides.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the practice? The facility reviewed and updated Facility Assessment to include HHA, PAR level, and Minimum PAR levels. The IDT met to review the assessment to ensure sufficient staffing for all units in the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The staffing coordinator will maintain the daily unit staffing sheet (RN, LPN, CNA, and HHA) of all units for sufficient staffing. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? The staffing coordinator will review and update the daily unit staffing sheet to include HHAs on the unit staffing sheet. The staffing coordinator will be responsible for maintaining the daily unit staffing sheet to be presented to the Director of Nursing. A random audit of the daily staffing sheet will be conducted by the Director of Nursing times weekly x 4 weeks, then monthly x 3 months. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? What quality assurance program will be put into practice? The Director of Nursing audit findings will be presented monthly and quarterly to the Quality Assurance and Improvement Committee. The facility will meet 100% compliance with such audit. All audits will be brought to QAPI monthly x 3 months. Completion Date: 1/16/25 Responsible person(s): Director of Nursing.