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) over a 14-day period from January 7, 2025, to January 20, 2025. A review of staffing documents and nursing staff schedules revealed that the facility consistently provided less than the required PPD hours on each of these days, with PPD hours ranging from 2.37 to 3.06. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 24, 2025, who acknowledged the facility's failure to meet the mandated staffing levels on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.