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 consecutive days from November 29, 2024, to December 3, 2024. A review of staffing documents and nursing staff schedules revealed that the facility provided 3.00 PPD on November 29, 3.17 PPD on November 30, 3.19 PPD on December 1, 2.93 PPD on December 2, and 3.09 PPD on December 3. During an interview on December 4, 2024, the Nursing Home Administrator confirmed the facility's failure to meet the required PPD hours on these 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: 11/29/24, 11/30/24, 12/1/24, 12/2/24 & 12/3/24. 2. The facility will ensure that the 3.2 state minimum direct resident care hours in each 24hr period is met. 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: 12/16/2024