Failure to Meet 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 per day. This deficiency was identified during a review of the facility's nursing staffing documents for the period from December 31, 2024, to January 6, 2025. Specifically, on January 5, 2025, the facility provided only 3.17 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on the same day.
Plan Of Correction
The Administrator and/or designee will provide education to the staffing coordinator, charge nurses, and administrative nurses on the state required minimum staffing of 3.2 hours of direct care per patient day requirements. A new staffing meeting will be conducted after the morning clinical meeting to review deployment sheets and the PA DOH staffing excel sheet. The current day and upcoming days will be reviewed at each meeting to ensure that the facility meets the required PPD at the projected census level. The Administrator will keep the admission team updated and informed. Attendees will be the Administrator, Scheduler, and Nursing Administration. The Administrator and/or designee will review staffing 4 times a week for 2 weeks, 3x weekly for 4 weeks to ensure that the state required minimum staffing minimum PPD requirement of 3.2. All audits will be reviewed through the Quality assurance/performance improvement process. The Administrator and/or designee will utilize recruitment platform and Indeed for job applicants, attend job fairs as able, corporate talent acquisition specialist, employee referral bonus program and tuition reimbursement for recruitment efforts. Charge Nurses will be provided with employee contact listings and will be responsible for calling staff when ratios are projected to be unmet. They will be able to offer our hourly call-in pay to help with incentive shift pick-ups. Call offs are to be addressed by these charge nurses to ensure staffing requirements are met.