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) for four out of twenty-one days reviewed. Specifically, on the dates of January 19, January 20, February 1, and February 2, 2025, the facility provided 3.06, 3.04, 3.11, and 2.88 PPD hours of direct care, respectively. This deficiency was identified through a review of nursing time schedules and staff interviews. The Nursing Home Administrator confirmed the failure to meet the required PPD hours during an interview conducted on February 6, 2025.
Plan Of Correction
1. The facility cannot correct that the PPDs were not met on 1/19/25, 1/20/25, 2/1/25 and 2/2/25. There were no adverse effects to the residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring PPDs are met for the day. A Daily staffing meeting will be held by administration to monitor PPD levels. Nursing supervisors will monitor on weekends. If the facility is projected to not meet PPD, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure PPDs are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.