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P5530

LPN Staffing Deficiency

Pottstown, Pennsylvania Survey Completed on 12-30-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with the staffing regulations for Licensed Practical Nurses (LPNs) as mandated effective July 1, 2023. Specifically, the facility did not maintain the required minimum of one LPN per 25 residents during the day shift on December 19 and 22, 2024. Additionally, the facility did not meet the requirement of one LPN per 30 residents during the evening shift on December 25 and 28, 2024. These deficiencies were identified through a review of the facility's staffing data and were confirmed with the Nursing Home Administrator on December 30, 2024, at 2:15 p.m.

Plan Of Correction

1. The facility is unable to retroactively provide minimum LPN coverage to meet minimum required staffing ratios from December 18th through December 29th, 2024. 2. A facility audit was completed to ensure LPN minimum staffing ratios were met. The Recruitment Team is recruiting more LPNs and ensuring wages are competitive with surrounding area facilities. Agency staff are being utilized to assist with meeting minimum LPN staffing ratios while recruitment continues. 3. The Nursing Scheduler/Designee was re-educated on ensuring nursing care LPN minimum staffing ratios are met, and that the facility is actively recruiting LPNs. 4. The Administrator or designee will conduct an audit of the nursing care LPN ratios to ensure compliance weekly for 4 weeks, then monthly for 2 months. The results will be submitted to the QAPI Committee for review and analysis of the need for ongoing monitoring.

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