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P5640

Failure to Meet Minimum Nursing Care Hours

Harmony, Pennsylvania Survey Completed on 12-12-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) for 15 out of 21 days reviewed. The deficiency was identified through a review of nursing time schedules and staff interviews. Specific days where the PPD fell short include 11/22/24 with 3.07 PPD, 11/23/24 with 3.13 PPD, and several other days where the PPD ranged from 2.83 to 3.19. The Director of Nursing confirmed the failure to meet the required PPD on these days during an interview on 12/12/24.

Plan Of Correction

The facility cannot correct that the PPD was below a 3.20 staffing level on 11/22/24, 11/23/24, 11/24/24, 11/25/24, 11/28/24, 11/29/24, 11/30/24, 12/1/24, 12/2/24, 12/3/24, 12/6/24, 12/7/24, 12/8/24, 12/9/24, 12/10/24. 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 PPDS 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 a given day, the scheduler/designee will be responsible to call off duty personnel or call extra support staff to assist. The Nursing Home Administrator or 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.

See complete original report
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