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 patient daily (PPD) for five out of seven days during the period from December 20, 2024, to December 26, 2024. A review of staffing documents and nurse schedules revealed that the facility did not meet the required PPD minimum hours on December 20, 21, 22, 23, and 24, 2024, with PPD hours recorded as 3.03, 3.04, 2.64, 3.04, and 3.1, respectively. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 26, 2024, at 2:00 p.m., who acknowledged the failure to provide the mandated level of direct care for each resident on the specified days.
Plan Of Correction
1. Staffing coordinator to be educated on maintaining a minimum PPD of 3.20 for direct care staff. 2. A scheduling app has been implemented for direct care staff and staff are acclimating to the procedures of applying for shifts and picking up open shifts. 3. Facility to conduct daily labor meetings attended by DON and NHA to manage direct care staff and monitor staffing calculation spreadsheet. 4. NHA/designee to educate DON and licensed nurses to alert NHA/DON to shortages and/or call offs. 5. NHA/designee to audit ratios 1/week for 6 weeks. 6. Results reported to QAPI for review and approval.