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P5640

Failure to Meet Minimum Direct Care Hours

Pittsburgh, Pennsylvania Survey Completed on 12-16-2024

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 two specific days. A review of staffing documents and nursing schedules from December 10, 2024, through December 15, 2024, revealed that the facility did not meet the required PPD hours on December 12, 2024, and December 15, 2024. On December 12, 2024, the facility provided 3.16 PPD hours, and on December 15, 2024, it provided only 2.94 PPD hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024, who acknowledged the failure to meet the required direct care hours on the specified dates.

Plan Of Correction

1. The facility cannot correct that the state required PPD (per patient daily) minimum hours of 3.20 was not met on 12/12/24 and 12/15/24. 2. The facility scheduler will continue to be educated regarding the state ratios and daily PPD by the NHA/designee. 3. The NHA, DON and scheduler will meet twice a day to review PPD and projected PPD. Nursing supervisors will monitor it on weekends. If the facility is projected to not meet daily PPD, the scheduler or designee will call off duty facility staff and utilize external staffing support resources. 4. NHA/designee will audit staffing daily for three weeks and monthly for three months to ensure daily PPD is being met. Outcomes will be reported to the QA&A committee for review and recommendations.

See complete original report
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