Failure to Meet Minimum Nursing 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 patient day (PPD) for 14 out of the 20 days reviewed. This deficiency was identified through a review of nursing staff care hours for specific weeks in November and December 2024. On several days, the facility's nursing care hours fell short of the required minimum, with the lowest recorded at 2.85 hours PPD. During a meeting on December 9, 2024, the Nursing Home Administrator confirmed the facility's failure to meet the required daily hours PPD as evidenced by the documented findings.
Plan Of Correction
1. While the facility cannot retroactively correct; since the staffing citations, the facility has hired 4 med nurses (2 RN and 2 LPN) along with 2 CNAs. Also, the facility has seen a total of 2 CNAs come off of orientation in the last 2 weeks that will now be included in the facility's HPPD. 2. Facility will conduct an audit consisting of the last two-week period of nursing staffing HPPDs. 3. The facility shall make reasonable attempts to acquire new staff, including offering competitive pay rates, shift differentials, partnering with local community schools, and offering employee benefits. 4. The NHA/Designee will educate the scheduler/designee on the requirements of meeting the minimum HPPD per the regulation. 5. The Scheduling Manager/Designee will randomly audit the HPPD weekly x's 3 weeks to ensure HPD regulatory compliance. Any concerns/issues will be reviewed monthly to the facility's QAPI Committee.