Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. This deficiency was identified through a review of the facility's staffing levels and confirmed by the Nursing Home Administrator. Specific dates were noted where the facility's nursing care hours fell below the mandated threshold, with the lowest recorded at 2.86 hours per resident. The deficiency was documented in accordance with the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, which stipulates the minimum nursing care hours effective July 1, 2024. The facility's failure to consistently provide the required nursing care hours was confirmed during an interview with the Nursing Home Administrator, highlighting a pattern of non-compliance with the staffing requirements.
Plan Of Correction
The facility cannot retroactively correct the deficiency cited by the surveyor related to not maintaining the required PPD on dates identified. The facility recognizes all residents have the potential to be affected. Please see sections 3 and 4 for system changes and monitoring. The nursing staff scheduler will be re-educated by the Nursing Home Administrator on the required minimum daily PPD. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. Calculation of daily PPD will be completed and reviewed for accuracy by the scheduler, DON, or NHA. All efforts will be made to meet the PPD daily. If call-offs occur, all efforts will be made to attempt to fill that position. Daily PPD will be audited weekly for 4 weeks and then monthly for 2 months. Results will be forwarded to the QA committee monthly for review and recommendations.