Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of staffing documents and confirmed through staff interviews. Specifically, on January 1, 2025, the facility provided only 3.18 hours of direct care per resident, 3.17 hours on January 2, 2025, and 3.18 hours on January 3, 2025. The Nursing Home Administrator confirmed the accuracy of the staffing information during an interview on January 9, 2025.
Plan Of Correction
1) Facility cannot retroactively correct. 2) NHA/designee will review PPDs for the last 4 weeks to ensure compliance and adherence to regulation. 3) NHA/Designee will re-educate staff scheduler and DON on regulation of PPD to ensure ongoing compliance. Facility will conduct daily staffing meeting to review PPDs to ensure ongoing compliance and systematic change. Facility will educate nursing staff on call off policy and hold weekly meeting to review call offs and enforce disciplinary action per call off policy. 4) NHA/Designee will conduct audit of projected PPDs 3 x a week x 4 weeks and once a month x 2 months to ensure compliance with regulation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance is met.