Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.20 hours of direct resident care per resident per day for four out of six days reviewed. Specifically, on January 3, 2025, the facility provided 3.16 hours, on January 4, 2025, 3.09 hours, on January 5, 2025, 3.02 hours, and on January 6, 2025, only 2.70 hours of direct care per resident. This deficiency was confirmed through a review of the facility's staffing documentation and an interview with the Director of Nursing, who acknowledged the shortfall in meeting the required care hours on those dates.
Plan Of Correction
Development and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth in the statement of deficiency. This plan of correction is prepared and/or executed by provision of Federal or State Law. 1. Residents received required care and there were no negative outcomes from the staffing level falling slightly below 3.2 ppd. 2. The facility has identified that all the residents have the potential to be affected by the average nursing care hours falling below 3.2 in a 24-hour period of direct resident care for each resident. 3. Facility will implement the critical staffing plan and will begin to utilize agency contracts to ensure the average nursing care hours are a minimum of 3.2 hours of direct resident care for each resident in a 24-hour period. Facility will ensure resident quality of care continues. 4. HR Director/Designee will conduct 3 random audits weekly for 1 month, and then 3 random audits monthly, to ensure that a minimum of 3.2 hours of direct resident care is provided for each resident in a 24-hr period. HR/Designee will report audit results monthly for Quality Assurance and Performance Improvement Committee to address any trends or patterns, need for further review, and or recommendations. 5. Date of compliance 2/3/25.