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) on three specific days within the review period. On January 18, 2025, the facility provided 3.08 PPD, on January 19, 2025, it provided 3.19 PPD, and on January 20, 2025, it provided 3.07 PPD. This deficiency was identified through a review of nursing time schedules and staff interviews. The Assistant Director of Nursing confirmed the shortfall in meeting the required PPD hours during an interview conducted on January 23, 2025.
Plan Of Correction
The facility cannot correct that the PPD was below a 3.20 staffing level on 1/18/25, 1/19/25, 1/20/25. The facility will ensure that PPD is met for every day. The Regional Clinical Consultant will re-educate the Nursing Home Administrator, Director of Nursing, and HR Director/Scheduler on regulation P5640 and making sure that PPDs are met. Daily schedules will be reviewed to monitor the projected PPD and the IDT will adjust if needed to ensure PPDs are met. The Nursing Supervisors will review staffing sheets on the weekends. If the facility projects to not meet PPD on any given day, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure PPDs are being met. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits.