Staffing Deficiencies at Hermitage Nursing and Rehabilitation
Penalty
Summary
Hermitage Nursing and Rehabilitation was found to be non-compliant with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to meet the required nurse aide (NA) to resident ratios on multiple occasions between January 22, 2025, and February 4, 2025. During the day shift, the facility did not meet the minimum requirement of one NA per 10 residents on two days. On the evening shift, the facility failed to meet the minimum requirement of one NA per 11 residents on four days. Additionally, the overnight shift did not meet the minimum requirement of one NA per 15 residents on four days. The staffing shortages were confirmed through a review of the facility's nursing staffing documents and an interview with the Nursing Home Administrator. The administrator acknowledged that the facility did not meet the required NA ratios on the specified dates and shifts. The report does not provide any information about the impact of these staffing shortages on the residents or any specific incidents that occurred as a result of the deficiencies.
Plan Of Correction
No residents were found to be negatively affected by the deficient practice of regulation. The facility will maintain one Nurse Aide for ten residents on day shift, one nurse aide for eleven residents for evening shifts, and one nurse aide to fifteen residents for night shift to meet minimum state regulation, as required and calculated by PA DOH Minimum Staffing Ratios. 1. The Administrator and/or designee will have a staffing meeting each business day morning, for four weeks to ensure proper staff to resident ratios meet shift requirements according to current censuses. The Census will be reviewed each business day morning to ensure the staff to resident ratio. Every weekend the Director of Nursing and Assistant Director of Nursing alternate to assure compliance. 2. We are going to educate all Clinical Managers on the call off practice. Immediately notify scheduler/Director of Nursing and call staff with the provided phone numbers of employed staff. Failure to find coverage must notify Director of Nursing immediately. The facility will utilize administration staff that have a certified nurse aide certification to maintain the required ratios for the certified nursing assistants, in the event of unforeseen shortage of certified nursing assistants. 3. Daily staffing sheets completed Monday through Friday. Human Resources and Scheduler meet to discuss PPD and ratios. Scheduler, Director of Nursing, Administrator, and Human Resources meet to review staffing schedules five times a week. The Facility will utilize On-shift program to make the schedule accessible to staff to see open shifts and pick them up. 4. Director of Nursing and Assistant Director of Nursing oversees the admission process to determine the appropriate level of care regarding ratios and PPD. 5. Administrator or designees will continue to recruit potential employees by placing ads on Indeed and other recruiting mediums, networking within the community through Facebook and other social media. 6. Referral bonus will be offered to employees to encourage candidates to apply. 7. The Administrator or designee will review the staffing concerns monthly in the Quality Assurance and Performance Improvement meeting. The scheduler and nursing supervisor will be educated on the requirements of staff in order to meet mandatory resident to staff ratios. 8. Active recruitment of employees at local medical facilities that are closing will be documented. 9. All auditing of the above process will be completed by the Nursing Home Administrator and Director of Nursing, or designee and documented five times weekly at a minimum to achieve compliance.