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P5520

Nurse Aide Staffing Ratio Not Met

Youngsville, Pennsylvania Survey Completed on 12-17-2024

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 required nurse aide (NA) staffing ratios during the day shift on December 7, 2024. Specifically, the regulation mandates a minimum of one NA per 10 residents during the day. On the day in question, the facility had a census of 125 residents, necessitating 12.50 NAs, but only 11.50 NAs were on duty. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 17, 2024.

Plan Of Correction

It is the policy of the Rouse Home to provide adequate staffing to meet the needs of all residents. Following the new staffing requirements issued July 1, 2024, the Rouse Home has implemented numerous new measures to assure that we are doing all that we can to meet the new nurse staffing requirements. Staffing is reviewed by the Nursing Home Administrator and Director of Nursing, and or designee daily. If the staffing schedule does not meet the ratio minimums, we put incentives out to all of the nursing staff via On-shift message, personal phone calls, and text messages, and incentives are offered for staff to pick up these shifts. Additionally, we have made changes to our time and attendance policy in efforts to minimize staff calling off their scheduled shift. In 2024, we held a total of two NA classes which has helped to increase the overall number of CNAs employed at the Rouse Home. We have significantly increased our recruitment efforts as well in 2024. Efforts include job postings on Indeed, Rouse website, Facebook, radio ads in various counties, and welcome walk-in interviews at any time. Our HR team attends job fairs and other local events to advertise open positions. We also market available opportunities at our local high schools as well as colleges and universities in Warren County and the surrounding areas. We market sign-on bonuses for new hires and also offer our current staff recruitment bonuses for referring anyone to the open nursing positions, and increased our 2nd and 3rd shift differentials as part of our recruitment and retention efforts. Going forward, the projected monthly schedule will be reviewed with the roll out of the schedule to identify any shifts that do not meet ratio. Once we identify these shifts, we will begin to proactively recruit to fill the open shift. Administrator, DON, Nurse Scheduler will audit daily staffing including CNA ratios, along with all steps taken to fill vacancies 5 days a week and ongoing. Results of the audits will be reviewed and recorded in the monthly QAPI meetings.

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