Failure to Meet Minimum Nursing Staffing Requirements
Penalty
Summary
The facility failed to meet the Pennsylvania State minimum nursing staffing regulations, which require a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. A review of staffing documents for the week of November 29, 2024, through December 5, 2024, revealed that the facility provided less than the required hours on six out of seven days. Specifically, the facility provided 3.10 hours on November 29, 2.81 hours on November 30, 2.57 hours on December 1, 2.85 hours on December 2, 2.56 hours on December 3, and 2.90 hours on December 5. During an interview on December 9, 2024, the Nursing Home Administrator and Director of Nursing acknowledged that the staffing levels did not meet the state requirements.
Plan Of Correction
Total staff hours cannot be corrected for dates. Calculations of PPD will be completed and reviewed daily for accuracy by the scheduler and DON to assure enough staff hours per patient day is scheduled to cover PPD of 3.2. Pickup shift bonuses for all staff pickups effective 6/29/24 and continue at this time, new hire incentives ongoing, such as sign-on bonus, LPN and RN wage scale as well as waging analysis and increased starting wages for CNA, LPN and RN staff as well as current staff. Facility will continue to offer facility CNA training site. Effective on 7/28/24 facility had all CNA'S move to an 8 hours work day increasing from 7.5 hours. Education will continue staffing ratios and potential for mandating due to call off coverage. Nurse staff meetings held on July 24th and 25th reviewing this as well as additional meetings with RN supervisors on 11/20/24. Schedules and CNA ratios will be audited daily by the scheduler and DON/designee for 11 weeks or until substantial compliance is achieved. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvement meeting.