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P5520

Staffing Deficiencies in Nurse Aide Ratios

Hanover, Pennsylvania Survey Completed on 12-11-2024

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 nurse aide staffing ratios across multiple shifts over a six-day period in December 2024. Specifically, the day shift was understaffed on all six days reviewed, with the number of nurse aides consistently falling short of the required full-time equivalent (FTE) needed to meet the minimum staff-to-resident ratio. For instance, on December 5, 2024, with a resident census of 115, the facility provided only 5.37 FTEs against the required 11.50. Similar shortfalls were observed on subsequent days, with the facility providing significantly fewer nurse aides than required. The evening and night shifts also experienced staffing deficiencies. On four of the six evenings reviewed, the facility did not meet the required nurse aide FTEs, with notable shortfalls such as providing only 7.10 FTEs against a required 10.36 on December 5, 2024. Additionally, the night shift was understaffed on two of the six nights, with the facility providing only 3.37 FTEs against a required 7.60 on December 5, 2024. The Nursing Home Administrator confirmed these deficiencies, attributing them to challenges related to illness among staff.

Plan Of Correction

1. Facility cannot retroactively correct this concern. 2. All residents are at risk of being affected by staffing levels. An audit of the grievance log on the days cited below staffing ratios will be audited for any grievances related to staffing. 3. Facility continues to partner with company in recruiting for the CNA classes. Will continue to offer bonuses when ratios are below minimum and attempt to mandate when call outs and absences occur. CNA agency rates were recently increased to assist with CNA coverage. Facility is limiting daily admissions as well. 4. NHA/designee will monitor staffing ratios and PPD daily to ensure appropriate levels are being met. Audits will be reviewed at QAPI to ensure compliance and quality care.

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