Failure to Meet Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 4 of 14 day shifts reviewed. According to the New Jersey Department of Health memo, effective February 1, 2021, the law requires one Certified Nurse Aide (CNA) for every eight residents during the day shift. However, the facility's Nurse Staffing Reports revealed deficiencies in staffing levels on four specific days. On December 1, 2024, there were 11 CNAs for 94 residents, requiring at least 12 CNAs. On December 7 and 8, 2024, there were 10 CNAs for 92 residents, requiring at least 11 CNAs. On December 14, 2024, there were 11 CNAs for 97 residents, requiring at least 12 CNAs. During an interview on December 19, 2024, the Licensed Nursing Home Administrator (LNHA), in the presence of the Director of Nursing (DON), Infection Preventionist (IP), Regional Clinical Consultant, LNHA in training, and the survey team, acknowledged the staffing deficiencies. The LNHA stated that the facility utilizes an "alert system" to contact agency nurses to fill any call-outs when staffing is deficient. Despite this system, the facility did not meet the required staffing ratios on the specified days, leading to the identified deficiency.
Plan Of Correction
S560 Staffing 1. It is the intent of Concord Healthcare and Rehabilitation Center to maintain staffing requirement in compliance with all state and federal regulation. Efforts to hire facility staff will continue until there are adequate staff to serve all residents. Until that time, the facility will utilize staffing agencies to fill any open spots in the schedule. 2. All residents have the potential to be affected by this practice. 3. Contracts with staffing agencies have been secured to supplement facility staff. Hiring and recruitment efforts including wage analysis and adjustments, pay for experience, online job listings, job fairs, shift differentials and referral bonuses are being utilized to become more competitive in the marketplace. Wage increases for CNAs went into effect January 1st, 2025. 4. The Administrator or Designee will review staffing schedules weekly to ensure adequate staffing for all shifts. The results of these reviews will be submitted to the QAPI committee through June 2025. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. QAPI is held on a quarterly basis.