Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on five out of seven days during the period from January 20, 2025, to January 26, 2025. A review of staffing documents and nursing staff schedules revealed that the facility provided only 2.38 PPD on January 20, 2.81 PPD on January 21, 2.70 PPD on January 22, 3.05 PPD on January 23, and 3.15 PPD on January 26. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 28, 2025, at 10:05 a.m., who acknowledged the failure to provide the required minimum hours of direct care on the specified dates.
Plan Of Correction
1. The facility will ensure state-required general nursing care hours in each 24 hr period will be a minimum of 3.2 hrs of direct resident care for each resident. The facility cannot correct that we did not meet the minimum PPD of 3.2 hrs on the following dates: (1/20/25 through 1/23/25 and 1/26/25). 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. Open positions will continue to be posted on various platforms including CCAC to attract new hires. We will continue with a weekly retention and recruitment meeting. We have help wanted signs on our property. We increased bonuses as incentive to pick up shifts. We utilize agency to fill needed shifts. We added a $2.00/hr shift differential for Nurse Aides on the evening shift and increased hourly rates for every LPN who was hired under our "No Benefits" rate. We will continue to review referrals to ensure we can meet their needs prior to accepting. 3. The Nursing Home Administrator will re-educate the Director of Nursing, HR Director/Scheduler and RN Supervisors on regulation P5640 ensuring a minimum of 3.2 direct resident care hrs are met in each 24hr period. Resident care hrs will be reviewed at our daily staffing meeting to ensure a minimum PPD of 3.2 is scheduled to be met. The RN Nursing Supervisors will continue to review direct resident care hrs on evenings and weekends. If the facilities projection to meet the state minimum fall below a 3.2 due to call offs, No Call No Shows etc, the RN Supervisors will be responsible to ask currently working staff to pick up a shift, call off duty personnel and/or call extra support staff via staffing agencies to assist as necessary. 4. The Nursing Home Administrator/designee will audit staffing sheets daily for three months to ensure the minimum 3.2 hrs of direct resident care for each resident is met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance: 2/24/2025