Facility Fails to Meet Required 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 17 out of 21 days reviewed. The deficiency was identified through a review of nursing time schedules and confirmed by staff interviews. Specific days in January 2025 were highlighted where the facility provided less than the required hours, with the lowest being 2.83 hours on January 26, 2025. The Nursing Home Administrator confirmed the shortfall in direct care hours during an interview on January 30, 2025. The deficiency was consistent across multiple days, indicating a systemic issue in staffing or scheduling that led to insufficient direct care hours for residents.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility cannot retroactively correct past staffing issues. To prevent a future occurrence, the scheduler will be reeducated on staffing Per Patient Day (PPD) to include expectations of Hours Per Patient Day and ratios by the director of nursing/designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources and scheduler to review ratio and PPD compliance for upcoming schedules. During staffing meeting discussion will be held on efforts to fill open slots to meet Hours Per Patient Day by contacting external agencies for staff and asking in house staff to cover additional shifts. To monitor and maintain ongoing compliance, the Director of Nursing/designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.