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P5640

Failure to Meet Minimum Direct Care Hours

Greensburg, Pennsylvania Survey Completed on 12-10-2024

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 requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on five out of eight days reviewed. Specifically, on the dates of December 3, 4, 7, 8, and 9, 2024, the facility provided 2.90, 2.83, 3.11, 3.00, and 3.01 PPD hours of care, respectively. This deficiency was identified through a review of nursing time schedules and staff interviews. The Director of Nursing confirmed the shortfall in meeting the required PPD hours during an interview conducted on December 10, 2024.

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. 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. Bonus for staff bringing in new employees is in place. 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.

See complete original report
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