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P5530

LPN Staffing Ratio Deficiency

Hanover, Pennsylvania Survey Completed on 02-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required minimum Licensed Practical Nurse (LPN) staffing ratios on specific shifts, as evidenced by a review of staffing documents and staff interviews. On January 25 and 26, 2025, during the evening shift, the facility had 109 residents but only 4.31 LPNs, falling short of the required 4.36 LPNs. Additionally, on January 26, 2025, during the overnight shift, there were 108 residents with only 2.06 LPNs, not meeting the required 2.70 LPNs. This deficiency was confirmed through an interview with the Director of Nursing on February 3, 2025.

Plan Of Correction

1. Facility cannot retroactively correct staffing deficiencies. 2. All residents are at risk for staffing levels that fail to meet minimum ratio requirements. 3. Facility continues to use recruiting services to fulfill staffing needs. Facility is currently re-evaluating LPN rates for hiring. Re-education will be provided to licensed nursing staff regarding staffing requirements and ratios. Facility continues to offer bonuses, use of agency, and mandate as needed to meet requirements. 4. NHA/DON will monitor daily staffing needs to ensure adequate licensed staffing is met. Audits will be reviewed at QAPI for ongoing compliance and quality assurance.

See complete original report
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