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 per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed that on several dates in February 2025, the facility provided less than the required nursing care hours. Specifically, on February 4, 5, 6, 7, 8, 9, and 10, the facility's direct care nursing hours per resident were below the mandated 3.2 hours, with the lowest being 2.68 hours on February 9, 2025. An interview with the Nursing Home Administrator on February 12, 2025, confirmed the facility's failure to consistently provide the minimum required general nursing care hours to each resident daily. This deficiency was identified through a review of nurse staffing records and resident census data, which highlighted the facility's inability to meet the regulatory requirements for nursing care hours on the specified dates.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.