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 four specific days. A review of staffing documents and nursing staff schedules from January 21, 2025, through January 28, 2025, revealed that the facility did not provide the required PPD on January 24, 26, 27, and 28, 2025. Specifically, the PPD hours were 2.73, 2.78, 3.01, and 3.00, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 29, 2025, who acknowledged the failure to meet the required staffing levels on the specified days.
Plan Of Correction
The Nursing schedule is created to ensure staffing ratios reflect the current census per shift to meet PPD. When additional staff is needed to meet PPD, shifts are posted on our staffing portal, bonuses are offered, and text messages are sent to staff. The Administrator or designee will educate Nursing Admin, the Scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review PPD and audited for 3 weeks. The Audits will be taken to QAPI for review.