Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over an eight-day period. Specifically, on December 4, 2024, the daylight shift did not have the required number of NAs, with only 81.30 hours provided instead of the required 84.00 hours for a census of 112 residents. On December 3, 2024, the evening shift was also understaffed, providing 74.20 hours instead of the required 76.36 hours for 112 residents. The night shift was particularly affected, with deficiencies noted on December 3, 4, 8, and 9, 2024. For instance, on December 3, 2024, only 51.20 hours were provided instead of the required 56.50 hours for 113 residents. Similar shortfalls occurred on the other noted dates, with the facility failing to meet the required staffing levels for the night shift. The Director of Nursing confirmed these staffing deficiencies during an interview on December 10, 2024.
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 1:10 nurse aide for days, 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 12/20/24 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. Current class has 3 students and preparation underway for next class in January. 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 call offs that affect minimum ratios. Hempfield Manor has raised all wages for certified aides. ALL trained staff is being asked to assist when CNA team is understaffed. 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.