Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on six out of twelve days reviewed. Specifically, on the dates of January 9, 10, 12, 16, 19, and 20, 2025, the facility provided less than the mandated hours, with PPD hours recorded as 3.16, 3.00, 2.83, 3.12, 2.96, and 3.01, respectively. This deficiency was identified through a review of nursing time schedules and staff interviews. The Nursing Home Administrator confirmed the shortfall in meeting the required PPD hours during an interview conducted on January 23, 2025.
Plan Of Correction
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 3.2 by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. 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 3.2 PPD 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 3.2 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 PPD minimum levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum PPD levels. Hempfield Manor offers extra on call pay for on call availability. Hempfield Manor has raised all wages for certified aides and licensed nursing staff. Nurse Staffing PPD Hours 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.