Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides across several shifts, as mandated by the regulation effective July 1, 2024. Specifically, the facility did not meet the minimum staffing requirements of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight for 6 out of the 63 shifts reviewed. This deficiency was identified through a review of nursing staff schedules and facility census data, which revealed discrepancies in the hours of care provided by nurse aides compared to the hours required based on the resident census. On multiple occasions, the facility's staffing levels fell short of the required hours of care. For instance, on October 20, 2024, the facility provided only 116.4 hours of care instead of the required 140 hours during the day shift. Similarly, on November 28, 2024, only 75.93 hours of care were provided overnight, falling short of the required 89.60 hours. These findings were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to meet state staffing requirements on specific dates.
Plan Of Correction
The Provider submits the following plan of correction in good faith and to comply with federal regulations. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct this issue. The NHA, DON, and Staffing Coordinator were educated by the Regional Nurse on the CNA staffing ratios for dayshift, evening shift, and nightshift. The NHA/designee will audit staffing ratios daily as well as projected ratios for the upcoming shifts using the PA DOH staffing grid to ensure the required CNA ratios are met. Results of these audits will be submitted to the Quality Assurance Committee to determine if further action is needed.