Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. Specifically, the regulation requires a minimum of 1 nurse aide per 12 residents during the day and evening shifts, and 1 nurse aide per 20 residents overnight. A review of the facility's staffing records revealed that on 12 out of 21 shifts reviewed, the facility did not provide the minimum required number of nurse aides. For instance, on February 4, 2025, the day shift had 6.75 nurse aides instead of the required 8.25 for a census of 99 residents, and the evening shift had 7.53 nurse aides instead of the required 8.42 for a census of 101 residents. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no excess higher-level staff available to compensate for the staffing shortfall. This failure to comply with staffing regulations was documented across multiple shifts, indicating a pattern of non-compliance with the mandated staffing levels.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.