Deficiency in Meeting Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period. Specifically, on December 25, 2024, February 1, 2025, and February 2, 2025, the facility provided only 2.97, 2.97, and 2.90 care hours per resident, respectively. These findings indicate that the facility did not consistently meet the mandated staffing levels on these days, resulting in a shortfall in the required direct care hours for residents.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.