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P5520

Staffing Deficiency in Nurse Aide Coverage

Elizabethtown, Pennsylvania Survey Completed on 12-17-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet the required staffing levels as per the regulation effective July 1, 2024, which mandates a minimum of one nurse aide per 10 residents during the day and one nurse aide per 15 residents overnight. A review of the facility's staffing data from December 2 through December 11, 2024, revealed deficiencies on specific dates. On December 5, 2024, the day shift did not have the required number of nurse aides, and the night shift was understaffed on both December 5 and December 7, 2024. These findings were confirmed with the Nursing Home Administrator during a telephone interview on December 16, 2024.

Plan Of Correction

Nursing Home Administrator/designee will audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing home administrator, Director of Nursing, and Scheduler/HR will hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Discussion to also include facility holding open interview times weekly for any walk-ins for immediate interviews. Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it affects facility ratios. Nursing Home Administrator will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

See complete original report
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