Facility Fails to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on ten out of seventeen days between December 16, 2024, and January 1, 2025. A review of nursing time schedules and staff interviews revealed that the facility's PPD hours fell short on specific dates, with the lowest being 2.53 PPD on December 26, 2024. The Nursing Home Administrator confirmed the deficiency during an interview on January 3, 2025, acknowledging the failure to meet the required PPD hours 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: 12/16/24, 12/21/24, 12/22/24, 12/25/24 through 12/28/24, and 12/30/24 through 1/1/25. 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 platforms to attract new hires. We will continue with a weekly retention and recruitment meeting. 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: 1/20/2025