Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the evening and night shifts over a specified period. Specifically, on one occasion, the facility did not provide the mandated one nurse aide per 11 residents during the evening shift, and on seven occasions, it did not provide one nurse aide per 15 residents during the night shift. This deficiency was identified through a review of staffing documents from January 9, 2025, to January 20, 2025, which showed discrepancies between the actual hours worked by nurse aides and the hours required based on the resident census. The Nursing Home Administrator confirmed these staffing shortfalls during an interview.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Hempfield Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Hempfield Manor credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:11 nurse aide for evenings and 1:15 nurse aide for nights by a proactive preview by the DON/Designee of daily staff assignments and schedules to ensure adequate staff coverage. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily for 3x weekly to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 2/14/25 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor is an approved site for Fairview Manor's Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month to also cover calloffs that affect minimum ratios. Hempfield Manor has raised all wages for certified aides. Hempfield Manor also offers on call shifts/pay to current staff to cover extra shifts. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.