Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident for two days during the week of December 29, 2024, through January 4, 2025. Specifically, on December 31, 2024, the staffing level was 3.00 hours of direct care per resident, and on January 4, 2025, it was 2.97 hours. This deficiency was identified through a review of nursing staffing schedules and confirmed during an interview with the facility administrator on February 13, 2025.
Plan Of Correction
No residents were negatively impacted by not meeting 3.20 PPD. The facility completed an audit of HPPD for the past 30 days. Variances were reviewed with the staffing coordinator and recorded on the facility audit tool. The Administrator re-educated the staffing coordinator on the required HPPD. The Administrator has reviewed staff recruitment and retention initiatives and has communicated those initiatives to the facility recruitment manager. The Administrator / Designee will audit centers HPPD 3 times per week for 4 weeks, then weekly for 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.