Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per patient day (PPD) on two specific days during the review period. On December 15, 2024, the facility provided only 3.01 hours PPD, and on December 16, 2024, it provided 3.15 hours PPD. This deficiency was identified through a review of nursing staffing hours for the weeks of November 24-30, 2024, December 15-21, 2024, and January 1-7, 2025. An interview with the Nursing Home Administrator and Director of Nursing on January 8, 2025, confirmed the failure to meet the required staffing levels on the specified dates.
Plan Of Correction
Licensure Nursing Services (HPPD) The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency within. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. There were no adverse effects to the residents of our facility as a result of decreased HPPD. 2. DON will re-educate the staffing coordinator/designee on the 3.2 HPPD staffing requirement and will provide education on calculating HPPD and adjusting staffing to attain the 3.2 HPPD. 3. Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the 3.2 minimum, then the facility will reach out to current staff and staffing agencies to meet the minimum requirement. The facility will continue to recruit staff through all platforms. 4. The staffing coordinator will conduct an audit of HPPD levels randomly to ensure HPPDs meet the minimum 3.2 HPPD. Results of the audits with trends will be reported through QA&A. 5. Date of Compliance February 20, 2025.