Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident each day. On January 19, 2025, the facility provided only 3.09 hours, on January 21, 2025, 3.05 hours, and on January 22, 2025, 3.10 hours of direct care nursing per resident. These staffing levels were below the mandated minimum requirement. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 24, 2025.
Plan Of Correction
The facility cannot retroactively correct the staffing PPD issues. The facility utilizes staffing agencies, bonuses for staff, and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements. To prevent this from reoccurring, the RDCS re-educated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.