Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period for 13 out of 21 days reviewed. This deficiency was identified through a review of the facility's nursing staffing documentation for the periods between October 14, 2024, and December 1, 2024. Specific days were noted where the hours of direct care fell below the required threshold, with the lowest being 2.94 hours on October 20, 2024. The deficiency was discussed with the Nursing Home Administrator and the Director of Nursing on December 3, 2024. The review highlighted multiple instances where the facility's staffing levels did not meet the state-mandated requirement, indicating a pattern of insufficient staffing to provide the necessary level of care to residents. No corrective actions or follow-up measures were mentioned in the report.
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 state required direct resident care hours of 3.2 per patient day (PPD). The NHA/designee will audit the daily PPD as well as the projected PPD for the upcoming day using the PA DOH grid to ensure the required PPD is being met. Results of these audits will be submitted to the quality assurance committee to determine if further action is needed.