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P5530

LPN Staffing Deficiency

Columbia, Pennsylvania Survey Completed on 01-17-2025

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 meet the state-mandated staffing requirements for Licensed Practical Nurses (LPNs) over a 10-day period from January 6, 2025, to January 16, 2025. Specifically, the facility did not provide the minimum required LPN coverage on several shifts. On the day shift, the facility was short on January 3, 11, and 12, 2025, with actual hours worked being less than the required 52.16 and 52.48 hours. On the evening shift, the facility was short on January 13, 2025, with actual hours worked being 40.25 instead of the required 43.73 hours. This deficiency was identified during a review of facility staffing data and was discussed with the Nursing Home Administrator (NHA) on January 17, 2025.

Plan Of Correction

1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Agency staff are being utilized in an effort to reach daily shift ratios. Programs such as Apploi, Indeed, and CareerLink will be utilized to enhance recruiting efforts. The facility will utilize Indeed ads. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week for 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee.

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