Failure to Meet 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 per day for five out of six days reviewed. Specifically, on December 5, 6, 7, 9, and 10, 2024, the facility provided only 2.18, 2.62, 3.08, 2.92, and 2.95 hours respectively. This deficiency was identified through a review of the facility's staffing documentation and confirmed by the Nursing Home Administrator (NHA) during an email exchange. The NHA acknowledged the shortfall in meeting the required care hours and attributed the deficiency to staffing challenges due to illnesses.
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 PPD will be audited for any grievances related to staffing. 3. Re-education was previously completed with nursing staff on staffing and minimum requirements. Will continue to offer bonuses when PPD is below minimum and attempt to mandate staff when call outs and absences occur. Agency rates for aides were recently increased to assist with staffing challenges. Facility is limiting daily admissions at this time. 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.